Provider Demographics
NPI:1790787992
Name:SPATAFORE, ANDREW E (MPT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:E
Last Name:SPATAFORE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330
Mailing Address - Country:US
Mailing Address - Phone:304-842-3137
Mailing Address - Fax:304-842-3138
Practice Address - Street 1:306 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-842-3137
Practice Address - Fax:304-842-3138
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2229225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7305129000Medicaid
WVP86537Medicare UPIN
WVSP4087691Medicare ID - Type Unspecified