Provider Demographics
NPI:1013584747
Name:ANDREW, THOMAS JAKE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAKE
Last Name:ANDREW
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 RUNNING W DR
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-2021
Mailing Address - Country:US
Mailing Address - Phone:307-680-4783
Mailing Address - Fax:
Practice Address - Street 1:508 STOCKTRAIL AVE STE D
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3582
Practice Address - Country:US
Practice Address - Phone:307-688-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist