Provider Demographics
NPI:1104837582
Name:GOETZ, ANDREW J (PT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:GOETZ
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:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249
Mailing Address - Country:US
Mailing Address - Phone:360-331-5272
Mailing Address - Fax:360-331-5848
Practice Address - Street 1:5522 S FREELAND AVE
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249
Practice Address - Country:US
Practice Address - Phone:360-331-5272
Practice Address - Fax:360-331-5848
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT0003656225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA125635OtherDEPT OF L AND I
WA8380842Medicaid
WAAB08090Medicare ID - Type Unspecified