Provider Demographics
NPI:1205085149
Name:REARDON, ANDREW P
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:P
Last Name:REARDON
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:PO BOX 62106
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93106-2106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:615-591-6601
Practice Address - Street 1:4151 FOOTHILL RD
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1110
Practice Address - Country:US
Practice Address - Phone:805-681-7781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8150225100000X
CAPT297890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT297890OtherMEDICAL LICENSE
TN446631Medicare PIN