Provider Demographics
NPI:1013238377
Name:FANDREY, JASON KYLE (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:KYLE
Last Name:FANDREY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 WESTERN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-1511
Mailing Address - Country:US
Mailing Address - Phone:715-693-7727
Mailing Address - Fax:715-693-7171
Practice Address - Street 1:1021 WESTERN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455-1511
Practice Address - Country:US
Practice Address - Phone:715-693-7727
Practice Address - Fax:715-693-7171
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11421-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist