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General NPI Number Information
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NPI Number | 1073134615
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Entity Type | Individual
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Provider Name | BRIAN WOOD LAT
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Gender | Male
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Dates
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Enumeration Date | 05/06/2020
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Last Update Date | 05/06/2020
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Provider Practice Location Address
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Address Line | 1950 WASHINGTON ST
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City | GRAFTON
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State | WI
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Zip | 53024-2103
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Country | US
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Telephone | 414-243-5853
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Fax |
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Provider Business Mailing Address
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Address Line | 217 S HIGHLAND AVE
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City | THIENSVILLE
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State | WI
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Zip | 53092-1805
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 1331-39
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License Number State | WI
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