Provider Demographics
NPI:1134470677
Name:SMALL, ANDREW AKIRA (MPHTYST, BSCAPP(HMS))
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:AKIRA
Last Name:SMALL
Suffix:
Gender:M
Credentials:MPHTYST, BSCAPP(HMS)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 E ERIE ST UNIT 231
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6103
Mailing Address - Country:US
Mailing Address - Phone:917-216-1704
Mailing Address - Fax:
Practice Address - Street 1:1201 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3360
Practice Address - Country:US
Practice Address - Phone:917-216-1704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY62034868225100000X
WI13998-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist