Provider Demographics
NPI:1518697929
Name:ISSA, ANDREW JACOB (OTR)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JACOB
Last Name:ISSA
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 OLD GLORY CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-8696
Mailing Address - Country:US
Mailing Address - Phone:209-480-5877
Mailing Address - Fax:
Practice Address - Street 1:2001 SOLAR DR STE 150
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0680
Practice Address - Country:US
Practice Address - Phone:805-604-1924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand