Provider Demographics
NPI:1003147851
Name:LEU-HENTHORN, ANDREA (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LEU-HENTHORN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 E HIGHWAY 37
Mailing Address - Street 2:
Mailing Address - City:TUTTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73089-8791
Mailing Address - Country:US
Mailing Address - Phone:405-381-9979
Mailing Address - Fax:405-689-2106
Practice Address - Street 1:4805 E HIGHWAY 37
Practice Address - Street 2:
Practice Address - City:TUTTLE
Practice Address - State:OK
Practice Address - Zip Code:73089-8791
Practice Address - Country:US
Practice Address - Phone:405-381-9979
Practice Address - Fax:405-689-2106
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P64796Medicare UPIN