Healthcare Provider Details

I. General information

NPI: 1447451455
Provider Name (Legal Business Name): JAMES E DONALDSON LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N GRANDVIEW BLVD SUITE 100
PEWAUKEE WI
53072-5531
US

IV. Provider business mailing address

2020 N 51ST ST
MILWAUKEE WI
53208-1746
US

V. Phone/Fax

Practice location:
  • Phone: 262-574-5185
  • Fax: 262-574-5193
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number847039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: