Provider Demographics
NPI:1417374026
Name:ANDERON, PRESTON JAMES (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:JAMES
Last Name:ANDERON
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4502
Mailing Address - Country:US
Mailing Address - Phone:301-620-7478
Mailing Address - Fax:301-620-7479
Practice Address - Street 1:141 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE 180
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4502
Practice Address - Country:US
Practice Address - Phone:301-620-7478
Practice Address - Fax:301-620-7479
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00005192255A2300X
PART0051682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer