Provider Demographics
NPI:1639949670
Name:LANDIS, ANDREW JERARD (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JERARD
Last Name:LANDIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 VERNON ST UNIT 58
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-3968
Mailing Address - Country:US
Mailing Address - Phone:530-604-1311
Mailing Address - Fax:
Practice Address - Street 1:568 N SUNRISE AVE STE 110
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3097
Practice Address - Country:US
Practice Address - Phone:916-865-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52944225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant