Provider Demographics
NPI:1689746364
Name:WODKA, ANDREW (BS,PT, MBA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WODKA
Suffix:
Gender:M
Credentials:BS,PT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:100 DENNIS ST SW
Practice Address - Street 2:SUITE A
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-6523
Practice Address - Country:US
Practice Address - Phone:360-704-3300
Practice Address - Fax:360-704-7676
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA192512OtherDEPT OF LABOR & INDUSTRY
WAP00208864OtherRAILROAD MEDICARE
WA3757WOOtherREGENCE BLUE SHIELD
WA8939766OtherCRIME VICTIMS
WA8413882Medicaid
WA8413882Medicaid