Provider Demographics
NPI:1316173586
Name:HOLLOWAY, ANDREW MARTIN (PT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:MARTIN
Last Name:HOLLOWAY
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:720 12TH ST SE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-6708
Practice Address - Country:US
Practice Address - Phone:253-735-3606
Practice Address - Fax:253-351-9807
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2517225100000X
WAPT 60252025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0291064OtherDEPT. OF LABOR AND INDUSTRIES
WA1316173586Medicaid
WA1316173586Medicaid