MEDICARE: BENJAMIN JACOB ANDRES PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	A2555	MN
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1922675677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN JACOB ANDRES PTA

Provider Business Mailing Address
First Line	:	940 WOODLAND AVE
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55812-1113
Country	:	US
Telephone Number	:	187-236-0812
Fax Number	:

Provider Business Practice Location Address
First Line	:	940 WOODLAND AVE
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55812-1113
Country	:	US
Telephone Number	:	218-723-6081
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2021
Last Update Date	:	09/14/2024

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