Provider Demographics
NPI:1598431058
Name:PLATT, ANDREW JACOB
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JACOB
Last Name:PLATT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 VICKI LN APT B
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-5991
Mailing Address - Country:US
Mailing Address - Phone:210-889-4935
Mailing Address - Fax:
Practice Address - Street 1:3101 LATHROP ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7426
Practice Address - Country:US
Practice Address - Phone:907-459-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
AK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker