Provider Demographics
NPI:1386970432
Name:SURPRENANT, TRACY R (DPT)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:R
Last Name:SURPRENANT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FEDERAL ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2832
Mailing Address - Country:US
Mailing Address - Phone:518-272-3324
Mailing Address - Fax:
Practice Address - Street 1:500 FEDERAL ST
Practice Address - Street 2:SUITE 302
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2832
Practice Address - Country:US
Practice Address - Phone:518-272-3324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400016220Medicare PIN