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General NPI Number Information
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NPI Number | 1326408279
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Entity Type | Individual
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Provider Name | SEAN RUSSELL WASSHAUSEN MA, LAT, ATC, CSCS
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Gender | Male
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Dates
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Enumeration Date | 03/03/2016
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Last Update Date | 03/20/2019
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Provider Practice Location Address
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Address Line | 445 W SWIFT CREEK LN
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City | AFTON
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State | WY
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Zip | 83110-8004
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Country | US
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Telephone | 307-248-0233
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Fax |
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Provider Business Mailing Address
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Address Line | 446 ROUNDS AVE
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City | NEW RICHMOND
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State | WI
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Zip | 54017-2041
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Country | US
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Telephone | 715-716-6914
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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 | 65
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License Number State | WY
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