Individual
TY WASMUTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
24138 BLUE HERON DR, BRILLION, WI 54110-9316
(920) 901-7843
Mailing address
24138 BLUE HERON DR, BRILLION, WI 54110-9316
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
W2538059201008
WI
Other
Enumeration date
06/26/2015
Last updated
06/26/2015
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