Provider Demographics
NPI:1285623942
Name:CARON, ANDRE B (PT)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:B
Last Name:CARON
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 1:463 TREMONT ST W STE 100
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3743
Mailing Address - Country:US
Mailing Address - Phone:360-874-0745
Mailing Address - Fax:360-874-0846
Practice Address - Street 1:463 TREMONT ST W STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366
Practice Address - Country:US
Practice Address - Phone:360-874-0745
Practice Address - Fax:360-874-0846
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT194332251X0800X
WAPT60780941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00640460OtherRAILROAD MEDICARE
FLP00640460OtherRAILROAD MEDICARE