Provider Demographics
NPI:1134428600
Name:HERRES, ANDREW ALLEN JR (LMP)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:ALLEN
Last Name:HERRES
Suffix:JR
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1695
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1409
Mailing Address - Country:US
Mailing Address - Phone:509-780-7822
Mailing Address - Fax:
Practice Address - Street 1:3316 1/2 4TH ST
Practice Address - Street 2:SUITE 4A
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4460
Practice Address - Country:US
Practice Address - Phone:509-780-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60110908225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist