Provider Demographics
NPI:1558900860
Name:SUPERAK, ANDREW (ATC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:SUPERAK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 DONOVAN CT
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4819
Mailing Address - Country:US
Mailing Address - Phone:530-304-9812
Mailing Address - Fax:
Practice Address - Street 1:315 W 14TH ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1914
Practice Address - Country:US
Practice Address - Phone:530-757-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer