Healthcare Provider Details

I. General information

NPI: 1114463056
Provider Name (Legal Business Name): ELAINE GONYA LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36500 AURORA DR
SUMMIT WI
53066-4899
US

IV. Provider business mailing address

36500 AURORA DR
SUMMIT WI
53066-4899
US

V. Phone/Fax

Practice location:
  • Phone: 262-434-2600
  • Fax: 262-434-2601
Mailing address:
  • Phone: 262-434-2600
  • Fax: 262-434-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number39-796
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: