Provider Demographics
NPI:1144039397
Name:BALTAZAR, ANDREW (PTA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BALTAZAR
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 MCHENRY RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6740
Mailing Address - Country:US
Mailing Address - Phone:847-885-0078
Mailing Address - Fax:
Practice Address - Street 1:404 MCHENRY RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-6740
Practice Address - Country:US
Practice Address - Phone:847-885-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.010311225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant