Healthcare Provider Details

I. General information

NPI: 1659346229
Provider Name (Legal Business Name): WILLIAM PICCONATTO P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 RAILROAD DR NW SUITE 102
ELK RIVER MN
55330-1463
US

IV. Provider business mailing address

21811 SUGAR LN
ROGERS MN
55374-9529
US

V. Phone/Fax

Practice location:
  • Phone: 763-441-8111
  • Fax: 763-441-9015
Mailing address:
  • Phone: 763-439-7589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2039
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1789
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: