Healthcare Provider Details

I. General information

NPI: 1013049402
Provider Name (Legal Business Name): AMY BEYER LAT, WCMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21140 W CAPITOL DR SUITE 4
PEWAUKEE WI
53072-2953
US

IV. Provider business mailing address

21140 W CAPITOL DR SUITE 4
PEWAUKEE WI
53072-2953
US

V. Phone/Fax

Practice location:
  • Phone: 262-754-1650
  • Fax: 262-754-0877
Mailing address:
  • Phone: 262-754-1650
  • Fax: 262-754-0877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number305-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: