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General NPI Number Information
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NPI Number | 1639949670
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Entity Type | Individual
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Provider Name | ANDREW JERARD LANDIS PTA
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Gender | Male
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Dates
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Enumeration Date | 01/02/2024
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Last Update Date | 01/02/2024
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Provider Practice Location Address
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Address Line | 568 N SUNRISE AVE STE 110
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City | ROSEVILLE
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State | CA
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Zip | 95661-3097
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Country | US
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Telephone | 916-865-1100
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Fax |
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Provider Business Mailing Address
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Address Line | 1675 VERNON ST UNIT 58
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City | ROSEVILLE
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State | CA
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Zip | 95678-3968
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Country | US
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Telephone | 530-604-1311
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 52944
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License Number State | CA
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