Healthcare Provider Details

I. General information

NPI: 1881729671
Provider Name (Legal Business Name): JASON ANDERSON LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST STE 120
WAUKESHA WI
53188-3402
US

IV. Provider business mailing address

1111 DELAFIELD ST STE 120
WAUKESHA WI
53188-3402
US

V. Phone/Fax

Practice location:
  • Phone: 262-521-9762
  • Fax: 262-521-1091
Mailing address:
  • Phone: 262-521-9762
  • Fax: 262-521-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number633-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: