Provider Demographics
NPI:1518599331
Name:FOO, ANDREW JUSTIN
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JUSTIN
Last Name:FOO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5914
Mailing Address - Country:US
Mailing Address - Phone:201-488-0488
Mailing Address - Fax:201-488-5787
Practice Address - Street 1:605 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5914
Practice Address - Country:US
Practice Address - Phone:201-488-0488
Practice Address - Fax:201-488-5787
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01912900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty