Provider Demographics
NPI:1578937686
Name:FENDER, TIMOTHY LUKE (ATC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LUKE
Last Name:FENDER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 76 BOX 2921
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319-0030
Mailing Address - Country:US
Mailing Address - Phone:864-980-4005
Mailing Address - Fax:
Practice Address - Street 1:HIRAHATA 64 MISAWA-KICHI
Practice Address - Street 2:BUILDING #656
Practice Address - City:MISAWA-SHI
Practice Address - State:AOMORI-KEN
Practice Address - Zip Code:0330012
Practice Address - Country:JP
Practice Address - Phone:315-226-1051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer