Provider Demographics
NPI:1255781662
Name:THOMAS, ANDRA (AT,C)
Entity type:Individual
Prefix:
First Name:ANDRA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 NORTH ATHERTON ST.
Mailing Address - Street 2:147D REC HALL
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:16802
Mailing Address - Country:US
Mailing Address - Phone:814-867-0478
Mailing Address - Fax:
Practice Address - Street 1:276 RECREATION BLDG
Practice Address - Street 2:147D
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16802-5701
Practice Address - Country:US
Practice Address - Phone:814-867-0478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART001512A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer