Provider Demographics
NPI:1073873048
Name:TIDD, ANDREA MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:MARIE
Last Name:TIDD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 13414
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 MEDICAL SQUADRON
Practice Address - Street 2:1900 VANDENBURG RD
Practice Address - City:HANSCOM AFB
Practice Address - State:AE
Practice Address - Zip Code:01731-5142
Practice Address - Country:US
Practice Address - Phone:781-225-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NPI1073873048363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant