Provider Demographics
NPI:1225464753
Name:GREEN, ANDREW (PT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6319 FLY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9357
Mailing Address - Country:US
Mailing Address - Phone:315-410-6200
Mailing Address - Fax:315-451-2095
Practice Address - Street 1:314 E 1ST ST
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-2927
Practice Address - Country:US
Practice Address - Phone:315-439-8840
Practice Address - Fax:315-410-5554
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist