1407079718 NPI number — ANDREA MARIE PRICE PHYSICIAN ASSISTANT

Table of content: ANDREA MARIE PRICE PHYSICIAN ASSISTANT (NPI 1407079718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407079718 NPI number — ANDREA MARIE PRICE PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRICE
Provider First Name:
ANDREA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PIERRE
Provider Other First Name:
ANDREA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407079718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7065 ARCHIBALD AVE STE 102 #304
Provider Second Line Business Mailing Address:
STE 102 #304
Provider Business Mailing Address City Name:
CORONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-549-1123
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7056 ARCHIBALD ST
Provider Second Line Business Practice Location Address:
STE 102 #304
Provider Business Practice Location Address City Name:
CORONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92880-8713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-549-1123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA14625 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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