Provider Demographics
NPI:1144784331
Name:MAZZEI, PHILIP JASON (LAT, ATC)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:JASON
Last Name:MAZZEI
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 GLADES DR
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-2539
Mailing Address - Country:US
Mailing Address - Phone:715-456-9109
Mailing Address - Fax:
Practice Address - Street 1:1200 OAKLEAF WAY # A
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-2245
Practice Address - Country:US
Practice Address - Phone:800-322-1747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2270-392255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer