Provider Demographics
NPI:1104506559
Name:FODOR, TY ANDREW
Entity type:Individual
Prefix:
First Name:TY
Middle Name:ANDREW
Last Name:FODOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 WESLEY WAY
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-6001
Mailing Address - Country:US
Mailing Address - Phone:509-839-8000
Mailing Address - Fax:
Practice Address - Street 1:1724 WESLEY WAY
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-6001
Practice Address - Country:US
Practice Address - Phone:509-839-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61465595111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor