Provider Demographics
NPI:1275562761
Name:RATHJEN, ANDREW L (PT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:L
Last Name:RATHJEN
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 1:3213 W NORTH FRONT ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4026
Mailing Address - Country:US
Mailing Address - Phone:308-381-2424
Mailing Address - Fax:308-381-3646
Practice Address - Street 1:3213 W NORTH FRONT ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4026
Practice Address - Country:US
Practice Address - Phone:308-381-2424
Practice Address - Fax:308-381-3646
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1360174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025243900Medicaid
NE099625Medicare PIN