Active NPI
Gary David Premo, ATC
- Athletic Trainer
- Waupaca, WI
National Provider Identifier
1710113105
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 979-039
- Practice address
- 800 Riverside Dr
Waupaca, WI 54981-1943 - Phone
- (715) 258-1053
- NPI assigned
- May 31, 2009
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 979-039 | WI | Primary |
Addresses
Primary practice location
800 Riverside Dr
Waupaca, WI 54981-1943
Mailing address
208 W Wisconsin St
Weyauwega, WI 54983-9069
Phone (715) 570-5889
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 979-039 | WI | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1243728000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1243728000000",
"number": "1710113105",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "208 W WISCONSIN ST",
"city": "WEYAUWEGA",
"state": "WI",
"postal_code": "549839069",
"telephone_number": "715-570-5889"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "800 RIVERSIDE DR",
"city": "WAUPACA",
"state": "WI",
"postal_code": "549811943",
"telephone_number": "715-258-1053"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PREMO",
"first_name": "GARY",
"middle_name": "DAVID",
"credential": "ATC",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2009-05-31",
"last_updated": "2009-05-31",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "WI",
"license": "979-039",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Waupaca, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 31, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.