Provider Demographics
NPI:1972937795
Name:WEATHERS, ANDY MICHAEL (RT(R), CV)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:MICHAEL
Last Name:WEATHERS
Suffix:
Gender:M
Credentials:RT(R), CV
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:MICHAEL
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RT(R), CV
Mailing Address - Street 1:1054 VINYARD DR
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-3314
Mailing Address - Country:US
Mailing Address - Phone:608-250-0550
Mailing Address - Fax:
Practice Address - Street 1:1054 VINYARD DR
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-3314
Practice Address - Country:US
Practice Address - Phone:608-250-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3192172471C1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C1101XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistCardiovascular-Interventional Technology