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General NPI Number Information
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NPI Number | 1952812372
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Entity Type | Individual
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Provider Name | JAKE RATHSACK
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Gender | Male
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Dates
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Enumeration Date | 10/12/2017
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Last Update Date | 06/26/2020
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Provider Practice Location Address
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Address Line | 712 ELMWOOD AVE
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City | OSHKOSH
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State | WI
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Zip | 54901-3517
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Country | US
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Telephone | 920-629-8583
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Fax |
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Provider Business Mailing Address
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Address Line | 3321 KIMBERLY CIR
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City | MANITOWOC
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State | WI
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Zip | 54220-1297
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2055
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License Number State | WI
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