Provider Demographics
NPI:1528478179
Name:COOL, SANDTANA
Entity type:Individual
Prefix:MS
First Name:SANDTANA
Middle Name:
Last Name:COOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-2806
Mailing Address - Country:US
Mailing Address - Phone:518-762-4548
Mailing Address - Fax:518-736-1570
Practice Address - Street 1:201 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-2806
Practice Address - Country:US
Practice Address - Phone:518-762-4548
Practice Address - Fax:518-736-1570
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037728-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0039494849Medicaid
NY335314002Medicare PIN