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General NPI Number Information
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NPI Number | 1093865495
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Entity Type | Individual
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Provider Name | BRIAN JP MCWILLIAMS MS, LAT, CSCS, CEAS
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Gender | Male
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 01/09/2015
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Provider Practice Location Address
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Address Line | 1002 GEORGE ST
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City | DE PERE
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State | WI
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Zip | 54115-2952
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Country | US
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Telephone | 920-360-4890
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Fax |
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Provider Business Mailing Address
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Address Line | 173 SULLIVAN LN
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City | DE PERE
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State | WI
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Zip | 54115-3771
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Country | US
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Telephone | 920-360-4890
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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 | 18-039
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License Number State | WI
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