Provider Demographics
NPI:1063718757
Name:FECTEAU, ANDREW J (PT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:FECTEAU
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912NWRIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2732
Mailing Address - Country:US
Mailing Address - Phone:541-280-4170
Mailing Address - Fax:541-610-1838
Practice Address - Street 1:1441SWCHANDLER AVE 104
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3208
Practice Address - Country:US
Practice Address - Phone:541-280-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2914208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR203430Medicaid
ORR158560Medicare PIN