Basic Information
| Provider Information | |||||||||
| NPI: | 1255381109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLETTI | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 331 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 122 W 7TH AVE STE 232 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094558820 | ||||||||
| FaxNumber: | 5098384978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0001X | MED-PHYS-LIC-12142 | MT | N | 207RC0000X | MD00043943 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | MD00043943 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RA0001X | MD00043943 | WA | Y |
ID Information
| ID | Type | State | Issuer | Description | 8402372 | 05 | WA | MEDICAID | 2547CO | 01 | WA | REGNECE BLUE SHIELD | OTHER | A058 | 01 | WA | TRI WEST (TRICARE) | OTHER | 0279971 | 01 | WA | L&I AND CRIME VICTIMS FOR PHMG | OTHER | 82107 | 01 | WA | L&I AND CRIME VICTIMS FOR SJMC | OTHER | MD6425 | 05 | AK | MEDICAID | 1255381109 | 05 | WA | MEDICAID | 5793737 | 01 | WA | AETNA | OTHER |