Provider Demographics
NPI:1477063725
Name:MCINTYRE, JESSE WADE (DAT, LAT, ATC, CSCS)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:WADE
Last Name:MCINTYRE
Suffix:
Gender:M
Credentials:DAT, LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 LA SALLE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-7916
Mailing Address - Country:US
Mailing Address - Phone:405-614-2024
Mailing Address - Fax:
Practice Address - Street 1:210 LA SALLE DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-7916
Practice Address - Country:US
Practice Address - Phone:405-614-2024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-01
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT76262255A2300X
GAAT0030212081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAT003021OtherATHLETIC TRAINER CERTIFIED AND LICENSED