Individual
RUSSELL DONALD DE LAP
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
12800 N LAKE SHORE DR, MEQUON, WI 53097-2418
(262) 243-4323
(262) 243-2969
Mailing address
1165 TOWER HILL DR, BROOKFIELD, WI 53045-6705
(262) 789-5040
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
4039
WI
Other
Enumeration date
02/15/2007
Last updated
07/08/2007
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