Provider Demographics
NPI:1366076796
Name:BROCKWAY, ANDREW THOMAS
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:THOMAS
Last Name:BROCKWAY
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 1:1120 RAINTREE CIR STE 280
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5258
Mailing Address - Country:US
Mailing Address - Phone:214-383-9356
Mailing Address - Fax:214-383-9886
Practice Address - Street 1:1120 RAINTREE CIR STE 280
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5258
Practice Address - Country:US
Practice Address - Phone:214-383-9356
Practice Address - Fax:214-383-9886
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT40332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer