Provider Demographics
NPI:1295134468
Name:ATALLA, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:ATALLA
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 1:622 EAGLE ROCK AVE
Mailing Address - Street 2:SUIT 104
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2994
Mailing Address - Country:US
Mailing Address - Phone:973-669-0078
Mailing Address - Fax:
Practice Address - Street 1:622 EAGLE ROCK AVE
Practice Address - Street 2:SUIT 104
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2994
Practice Address - Country:US
Practice Address - Phone:973-669-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00311300225200000X
NJ40QA01805500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant