Provider Demographics
NPI:1740697283
Name:HAMSTRA, ANDREW (MS ATC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:HAMSTRA
Suffix:
Gender:M
Credentials:MS ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 BRITTON LN
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-8794
Mailing Address - Country:US
Mailing Address - Phone:720-280-1042
Mailing Address - Fax:
Practice Address - Street 1:626 BRITTON LN
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-8794
Practice Address - Country:US
Practice Address - Phone:720-280-1042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0022432255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer