Basic Information
| Provider Information | |||||||||
| NPI: | 1326596818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASANOVA | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | D-PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 PYLE DR | ||||||||
| Address2: | |||||||||
| City: | KINGSFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498024452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067743779 | ||||||||
| FaxNumber: | 9067746712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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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 | 5501017255 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.