Provider Demographics
NPI:1033449681
Name:KESACK, ANDREA FELLERMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:FELLERMAN
Last Name:KESACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:DAWN
Other - Last Name:FELLERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1253 APPALACHIN RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE GLEN
Mailing Address - State:PA
Mailing Address - Zip Code:19002-1151
Mailing Address - Country:US
Mailing Address - Phone:570-283-4806
Mailing Address - Fax:
Practice Address - Street 1:1253 APPALACHIN RD
Practice Address - Street 2:
Practice Address - City:MAPLE GLEN
Practice Address - State:PA
Practice Address - Zip Code:19002-1151
Practice Address - Country:US
Practice Address - Phone:215-646-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062401L207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine