Provider Demographics
NPI:1205243490
Name:SIMON-WAMBACH, ANDREW (ATC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:SIMON-WAMBACH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16546-0002
Mailing Address - Country:US
Mailing Address - Phone:608-206-7862
Mailing Address - Fax:
Practice Address - Street 1:501 E 38TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16546-0002
Practice Address - Country:US
Practice Address - Phone:608-206-7862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-19
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0055722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer