Provider Demographics
NPI:1952837494
Name:MUTNAN, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MUTNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109J LASCH FOOTBALL BUILDING
Mailing Address - Street 2:
Mailing Address - City:UNIVERISTY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:16802
Mailing Address - Country:US
Mailing Address - Phone:775-223-7238
Mailing Address - Fax:
Practice Address - Street 1:1547 NE COLORADO STREET
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164
Practice Address - Country:US
Practice Address - Phone:775-223-7238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0602021672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer