Provider Demographics
NPI:1518908573
Name:TIECHNER, JAC R (DPM)
Entity Type:Individual
Prefix:DR
First Name:JAC
Middle Name:R
Last Name:TIECHNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2025
Mailing Address - Country:US
Mailing Address - Phone:509-662-2970
Mailing Address - Fax:509-665-9808
Practice Address - Street 1:616 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2025
Practice Address - Country:US
Practice Address - Phone:509-662-2970
Practice Address - Fax:509-665-9808
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000207213E00000X, 213ES0103X, 213ER0200X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA15520000OtherWA STATE LABOR AND INDUSTRY
WA0035677OtherWA STATE LABOR AND INDUSTRY GROUP #
WA480661080OtherPALMETTO GBA RAILROAD MEDICARE PART B
WA1013614Medicaid
WA480661080OtherPALMETTO GBA RAILROAD MEDICARE PART B
WAGAB11091Medicare ID - Type UnspecifiedMEDICRE B PROVIDER NUMBER
WA1013614Medicaid