Provider Demographics
NPI:1538355219
Name:ROSENDAHL, ANDREW MARCUS (IDC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:MARCUS
Last Name:ROSENDAHL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1912 FALCON DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-2715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1912 FALCON DRIVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374
Practice Address - Country:US
Practice Address - Phone:361-563-9720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant