Provider Demographics
NPI:1952678443
Name:MORITZ, ANDREW JOHN (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JOHN
Last Name:MORITZ
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 GOODRICH AVENUE APT 5
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2090 WOODWINDS DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2522
Practice Address - Country:US
Practice Address - Phone:507-227-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer