Provider Demographics
NPI:1659346229
Name:PICCONATTO, WILLIAM (PT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:PICCONATTO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21811 SUGAR LN
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-9529
Mailing Address - Country:US
Mailing Address - Phone:763-439-7589
Mailing Address - Fax:
Practice Address - Street 1:555 RAILROAD DR NW
Practice Address - Street 2:SUITE 102
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1463
Practice Address - Country:US
Practice Address - Phone:763-441-8111
Practice Address - Fax:763-441-9015
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2039225100000X
MN17892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer