Provider Demographics
NPI:1073575908
Name:BROCK, ANDREA GENTRY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:GENTRY
Last Name:BROCK
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:128 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8578
Mailing Address - Country:US
Mailing Address - Phone:704-658-1001
Mailing Address - Fax:704-658-1002
Practice Address - Street 1:128 MEDICAL PARK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8578
Practice Address - Country:US
Practice Address - Phone:704-658-1001
Practice Address - Fax:704-658-1002
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-08-07
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Provider Licenses
StateLicense IDTaxonomies
NC103497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC20759342Medicare PIN