Provider Demographics
NPI:1841576063
Name:SMISKO, ANDREA C (PT)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:C
Last Name:SMISKO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:C
Other - Last Name:HUOTARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2090
Mailing Address - Fax:
Practice Address - Street 1:2400 W MALLARD CREEK CHURCH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2324
Practice Address - Country:US
Practice Address - Phone:704-323-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP18974225100000X, 225100000X
WAPT60740744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC397730041OtherNSC #