Provider Demographics
NPI:1841563335
Name:ANDREASEN, ERIC (MPT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ANDREASEN
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 1:475 CITY STREET
Mailing Address - Street 2:PO BOX 173
Mailing Address - City:NEWDALE
Mailing Address - State:ID
Mailing Address - Zip Code:83436
Mailing Address - Country:US
Mailing Address - Phone:208-458-4721
Mailing Address - Fax:
Practice Address - Street 1:393 EAST SECOND NORTH
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-359-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1527225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist