Provider Demographics
NPI:1083228514
Name:BOAN, ANDREA DENISE (PA-C, PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:DENISE
Last Name:BOAN
Suffix:
Gender:F
Credentials:PA-C, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 RUTLEDGE AVE # MSC561
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8903
Mailing Address - Country:US
Mailing Address - Phone:843-876-1064
Mailing Address - Fax:
Practice Address - Street 1:12 COMMERCIAL ROW APT A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3641
Practice Address - Country:US
Practice Address - Phone:864-506-2319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant