MEDICARE: CASSANDRA L SEMON LAT, ATC

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
1	2255A2300X	Athletic Trainer	3123-39	WI

General Provider Information

NPI Number	:	1922874544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSANDRA L SEMON LAT, ATC

Provider Business Mailing Address
First Line	:	942 ASH ST
Second Line	:
City	:	PRENTICE
State	:	WI
Zip	:	54556-1006
Country	:	US
Telephone Number	:	715-560-2469
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 NORTH ST
Second Line	:
City	:	RIB LAKE
State	:	WI
Zip	:	54470-9793
Country	:	US
Telephone Number	:	715-427-3220
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2023
Last Update Date	:	11/27/2023

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