Provider Demographics
NPI:1659973295
Name:SMITH, ANDREW (LMT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 NE 10TH ST # 426
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-1402
Mailing Address - Country:US
Mailing Address - Phone:503-334-4845
Mailing Address - Fax:
Practice Address - Street 1:1017 SW MORRISON ST STE 216
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2631
Practice Address - Country:US
Practice Address - Phone:503-334-4845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT019877172M00000X
OK183959172M00000X
OR8727172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist