1528042041 NPI number — MRS. AMY ELIZABETH GUNDERSON LICENSED ATHLETIC TR

Table of content: MRS. AMY ELIZABETH GUNDERSON LICENSED ATHLETIC TR (NPI 1528042041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528042041 NPI number — MRS. AMY ELIZABETH GUNDERSON LICENSED ATHLETIC TR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNDERSON
Provider First Name:
AMY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED ATHLETIC TR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNUTSON
Provider Other First Name:
AMY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
ATC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1528042041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8075
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WISCONSIN RAPIDS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54495-8075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-421-5257
Provider Business Mailing Address Fax Number:
715-421-0111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 DEWEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WISCONSIN RAPIDS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54494-4715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-421-5257
Provider Business Practice Location Address Fax Number:
715-421-0111
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  118039 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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