Provider Demographics
NPI:1215446133
Name:WOLF, ANDREW DAVID (PTA)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:DAVID
Last Name:WOLF
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11447 ANDERSON LAKES PKWY APT 367
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-4091
Mailing Address - Country:US
Mailing Address - Phone:612-384-1637
Mailing Address - Fax:
Practice Address - Street 1:11447 ANDERSON LAKES PKWY APT 367
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-4091
Practice Address - Country:US
Practice Address - Phone:612-384-1637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2189225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant