Provider Demographics
NPI:1609490572
Name:MOEN, ANDREW (DPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MOEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W9533 YANKEE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:BLANCHARDVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53516-9628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2448 S 102ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2466
Practice Address - Country:US
Practice Address - Phone:414-329-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist