Provider Demographics
NPI:1922675677
Name:ANDRES, BENJAMIN JACOB (PTA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JACOB
Last Name:ANDRES
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-2533
Mailing Address - Country:US
Mailing Address - Phone:715-573-6364
Mailing Address - Fax:
Practice Address - Street 1:35 N 28TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5557
Practice Address - Country:US
Practice Address - Phone:715-392-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2555225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant