Provider Demographics
NPI:1669004693
Name:MARISCAL, ANDREW JEREMY
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JEREMY
Last Name:MARISCAL
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 1:1045 ASHFORD CHASE CT
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-8027
Mailing Address - Country:US
Mailing Address - Phone:478-550-2624
Mailing Address - Fax:
Practice Address - Street 1:1045 ASHFORD CHASE CT
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-8027
Practice Address - Country:US
Practice Address - Phone:478-550-2624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer