Provider Demographics
NPI:1215123492
Name:FEGAN, TINAMARIE (LPTA)
Entity type:Individual
Prefix:MRS
First Name:TINAMARIE
Middle Name:
Last Name:FEGAN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MAITLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-3209
Mailing Address - Country:US
Mailing Address - Phone:781-961-6629
Mailing Address - Fax:
Practice Address - Street 1:501 JOHN MAHAR HWY
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-6599
Practice Address - Country:US
Practice Address - Phone:781-356-1016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3300225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant