Healthcare Provider Details

I. General information

NPI: 1508275652
Provider Name (Legal Business Name): ANDREW WAER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2014
Last Update Date: 08/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 KING RD
IMMACULATA PA
19345-9903
US

IV. Provider business mailing address

590 LOWER LANDING RD APT 5F
BLACKWOOD NJ
08012-4205
US

V. Phone/Fax

Practice location:
  • Phone: 610-647-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT005909
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberJ3-0000436
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00197100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: