Provider Demographics
NPI:1538658216
Name:TEGNANDER, JOE WILLIAM
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:WILLIAM
Last Name:TEGNANDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12222-0100
Mailing Address - Country:US
Mailing Address - Phone:518-442-3725
Mailing Address - Fax:
Practice Address - Street 1:1400 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12222-0100
Practice Address - Country:US
Practice Address - Phone:518-442-3725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002182-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2255A2300XOtherATHLETIC TRAINER