Provider Demographics
NPI:1780627083
Name:DAVIS, ANDREW BRIAN (MSPT LAT)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:BRIAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MSPT LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225000 HUMMINGBIRD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225000 HUMMINGBIRD RD STE 100
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2950
Practice Address - Country:US
Practice Address - Phone:715-359-6442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9563024225100000X
WI2790392255A2300X
WI9563-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41810500Medicaid
WI69530OtherSECURITY HEALTH
WI41810500Medicaid