Provider Demographics
NPI:1992456420
Name:WOLAK, ANDREW JOSEPH (PT, DPT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JOSEPH
Last Name:WOLAK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 PUEBLO TRL
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:NJ
Mailing Address - Zip Code:07462-3148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:923 HALE LAKE POINTE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-9615
Practice Address - Country:US
Practice Address - Phone:218-326-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-32119225100000X
MN12507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist