=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295551240
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KONNOR GERALD KINGSMORE LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2024
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N91W15750 FALLS PKWY
-----------------------------------------------------
City | MENOMONEE FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53051-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-532-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W64N14273 WASHINGTON AVE APT 129
-----------------------------------------------------
City | CEDARBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53012-3035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-510-5126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 3219-39
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------