Provider Demographics
NPI:1285087684
Name:MARCARELLI, ANDREW
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:MARCARELLI
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 1:696 CANYON ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3230
Mailing Address - Country:US
Mailing Address - Phone:714-475-4227
Mailing Address - Fax:
Practice Address - Street 1:29 BLACK COAL DR
Practice Address - Street 2:
Practice Address - City:FT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-332-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO365673247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist