Provider Demographics
NPI:1740679075
Name:MATTSON, ANDREA ALICE (PTA)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:ALICE
Last Name:MATTSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 CONSTITUTION AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7513
Mailing Address - Country:US
Mailing Address - Phone:505-296-5565
Mailing Address - Fax:
Practice Address - Street 1:3550 OLD AIRPORT RD NW
Practice Address - Street 2:2318
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-9266
Practice Address - Country:US
Practice Address - Phone:505-463-0723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA240225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant