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General NPI Number Information
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NPI Number | 1124610597
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Entity Type | Individual
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Provider Name | SAMUAL DEAN KOTSONAS
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Gender | Male
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Dates
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Enumeration Date | 02/08/2021
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Last Update Date | 02/08/2021
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Provider Practice Location Address
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Address Line | 2001 ALFORD DR
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City | KENOSHA
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State | WI
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Zip | 53140-1927
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Country | US
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Telephone | 952-300-7222
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Fax |
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Provider Business Mailing Address
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Address Line | 14521 GENESEE AVE
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City | APPLE VALLEY
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State | MN
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Zip | 55124-8420
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State | WI
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