Provider Demographics
NPI:1730869462
Name:ANDRIESE, MARK RYAN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RYAN
Last Name:ANDRIESE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 W MARCH LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6458
Mailing Address - Country:US
Mailing Address - Phone:209-302-2275
Mailing Address - Fax:
Practice Address - Street 1:1803 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6458
Practice Address - Country:US
Practice Address - Phone:209-302-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist