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NPI Code Detail

MEDICARE: MRS. AMY ELIZABETH GUNDERSON LICENSED ATHLETIC TR

MEDICARE: MRS. AMY ELIZABETH GUNDERSON LICENSED ATHLETIC TR
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer118039WI

General Provider Information

NPI Number : 1528042041
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. AMY ELIZABETH GUNDERSON LICENSED ATHLETIC TR
Provider Business Mailing Address
First Line : PO BOX 8075
Second Line :
City : WISCONSIN RAPIDS
State : WI
Zip : 54495-8075
Country : US
Telephone Number : 715-421-5257
Fax Number : 715-421-0111
Provider Business Practice Location Address
First Line : 410 DEWEY ST
Second Line :
City : WISCONSIN RAPIDS
State : WI
Zip : 54494-4715
Country : US
Telephone Number : 715-421-5257
Fax Number : 715-421-0111
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/30/2005
Last Update Date : 07/08/2007

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