Healthcare Provider Details

I. General information

NPI: 1972128775
Provider Name (Legal Business Name): ANDREW JUSTIN MOTZ EMT-B
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MASSACHUSETTS AVE
CAMBRIDGE MA
02139-4307
US

IV. Provider business mailing address

6542 80TH AVE SE
MERCER ISLAND WA
98040-5220
US

V. Phone/Fax

Practice location:
  • Phone: 617-252-1212
  • Fax:
Mailing address:
  • Phone: 206-661-2671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number0917254
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: