MEDICARE: MR. JOE WILLIAM TEGNANDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	002182-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2255A2300X	OTHER	NY	ATHLETIC TRAINER

General Provider Information

NPI Number	:	1538658216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOE WILLIAM TEGNANDER

Provider Business Mailing Address
First Line	:	1400 WASHINGTON AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12222-0100
Country	:	US
Telephone Number	:	518-442-3725
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 WASHINGTON AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12222-0100
Country	:	US
Telephone Number	:	518-442-3725
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2018
Last Update Date	:	05/08/2018

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