Provider Demographics
NPI:1386810265
Name:GONZALES, ANDREW JAMES (MPT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMES
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6726 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3525
Mailing Address - Country:US
Mailing Address - Phone:314-647-0081
Mailing Address - Fax:314-647-5485
Practice Address - Street 1:6726 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-3525
Practice Address - Country:US
Practice Address - Phone:314-647-0081
Practice Address - Fax:314-647-5485
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007038039225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2007038039Medicare Oscar/Certification