Provider Demographics
NPI:1427140755
Name:MYERS, ANDREA R (PT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:MYERS
Suffix:
Gender:F
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:PO BOX 9372
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-9372
Mailing Address - Country:US
Mailing Address - Phone:763-533-0541
Mailing Address - Fax:
Practice Address - Street 1:4080 W BROADWAY AVE
Practice Address - Street 2:300
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-5604
Practice Address - Country:US
Practice Address - Phone:763-533-0541
Practice Address - Fax:763-533-1052
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH051515225100000X
MN6287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2381515OtherMOLINA MEDICAID
1427140755OtherNPI
650024753OtherRR MEDICARE
WV7303087000Medicaid
000000217253OtherANTHEM BCBS
OH353666853-00OtherOH BUREAU WORKERS COMP
OH2381515OtherMOLINA MEDICAID