Provider Demographics
NPI:1679870836
Name:RADER, ANDREW ADAM (LAC)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:ADAM
Last Name:RADER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7282 SIR FRANCIS DRAKE BLVD
Mailing Address - Street 2:BOX 114
Mailing Address - City:LAGUNITAS
Mailing Address - State:CA
Mailing Address - Zip Code:94938
Mailing Address - Country:US
Mailing Address - Phone:415-488-0201
Mailing Address - Fax:
Practice Address - Street 1:7282 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAGUNITAS
Practice Address - State:CA
Practice Address - Zip Code:94938
Practice Address - Country:US
Practice Address - Phone:415-488-0201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3126171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist