Provider Demographics
NPI:1841578846
Name:MISNER, ANDREW STEPHEN (DPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:STEPHEN
Last Name:MISNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:510 N GRANDSTAFF DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-1660
Practice Address - Country:US
Practice Address - Phone:260-927-9270
Practice Address - Fax:260-927-9272
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010612A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN156546OtherGROUP MEDICARE
IN100257920BOtherGROUP MEDICAID