Provider Demographics
NPI:1669790192
Name:ELIASON, ANDREW MARK (DC)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MARK
Last Name:ELIASON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 46TH AVE N APT 37
Mailing Address - Street 2:
Mailing Address - City:KENNETH CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33709-3153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6705-B 38TH AVENUE. N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710
Practice Address - Country:US
Practice Address - Phone:727-381-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10001111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor