Provider Demographics
NPI:1598950487
Name:HOLRATH, ANDREA LYN (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYN
Last Name:HOLRATH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 PARK PL
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1883
Mailing Address - Country:US
Mailing Address - Phone:903-649-3433
Mailing Address - Fax:
Practice Address - Street 1:4317 PARK PL
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1883
Practice Address - Country:US
Practice Address - Phone:903-649-3433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2063450225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2063450OtherPTA LICENSE #