Provider Demographics
NPI:1346205937
Name:MIX, M ANDREW (RPT)
Entity Type:Individual
Prefix:
First Name:M ANDREW
Middle Name:
Last Name:MIX
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 EASTLAND DR N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4458
Mailing Address - Country:US
Mailing Address - Phone:208-735-8563
Mailing Address - Fax:208-735-8564
Practice Address - Street 1:276 EASTLAND DR N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4458
Practice Address - Country:US
Practice Address - Phone:208-735-8563
Practice Address - Fax:208-735-8564
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1352225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010141846OtherREGENCE
ID806571300Medicaid
IDT7275OtherBLUE CROSS
ID806555000Medicaid
IDP00045805OtherRAILROAD MEDICARE
ID806571300Medicaid