MEDICARE: MR. BRIAN WAYNE RAZAK 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	174400000X	Specialist	24-00058	KS

General Provider Information

NPI Number	:	1932165362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN WAYNE RAZAK LAT, ATC

Provider Business Mailing Address
First Line	:	2317 DONALD DR
Second Line	:
City	:	HAYS
State	:	KS
Zip	:	67601-2307
Country	:	US
Telephone Number	:	785-650-4647
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 PARK ST
Second Line	:	FORT HAYS STATE UNIVERSITY
City	:	HAYS
State	:	KS
Zip	:	67601-4009
Country	:	US
Telephone Number	:	785-628-5823
Fax Number	:	785-628-4383

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

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	07/08/2007

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