Basic Information
| Provider Information | |||||||||
| NPI: | 1083666044 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DEXTER | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1777 ASHLEY CIR | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707930395 | ||||||||
| FaxNumber: | 2707930765 | ||||||||
| Practice Location | |||||||||
| Address1: | 1777 ASHLEY CIR | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707930395 | ||||||||
| FaxNumber: | 2707930765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 09/06/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT004206 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 87001541 | 05 | KY | MEDICAID |