Basic Information
| Provider Information | |||||||||
| NPI: | 1104489772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDRE | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 724557 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311391557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578734115 | ||||||||
| FaxNumber: | 7578739619 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 MILL ST NE STE E | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221804500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039918156 | ||||||||
| FaxNumber: | 7039918158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2019 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305212621 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2305212621 | 01 | VA | VA PT LICENSE | OTHER |