=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548944945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY JOHN BALTIERRA LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2023
-----------------------------------------------------
Last Update Date | 06/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 22ND AVE
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53566-1569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-324-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 MEADOW DR
-----------------------------------------------------
City | ORANGEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61060-9218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-541-8214
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------