Provider Demographics
NPI:1295247179
Name:AMUNDSON, ANDREW WADE (DPT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:WADE
Last Name:AMUNDSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14287 SHORE LN NE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1274
Mailing Address - Country:US
Mailing Address - Phone:952-457-3558
Mailing Address - Fax:
Practice Address - Street 1:3305 CENTRAL PARK VILLAGE DR STE 130
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-7707
Practice Address - Country:US
Practice Address - Phone:651-406-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13410225100000X
IN05012500A.225100000X
MD27399225100000X
MN10639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist