Basic Information
| Provider Information | |||||||||
| NPI: | 1689746364 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WODKA | ||||||||
| FirstName: | ANDREW | ||||||||
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| Credential: | BS,PT, MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 DENNIS ST SW | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TUMWATER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985016523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607043300 | ||||||||
| FaxNumber: | 3607047676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 07/18/2015 | ||||||||
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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 | PT00009524 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 192512 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER | P00208864 | 01 | WA | RAILROAD MEDICARE | OTHER | 3757WO | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8939766 | 01 | WA | CRIME VICTIMS | OTHER | 8413882 | 05 | WA | MEDICAID |