Provider Demographics
NPI:1154301463
Name:JOLLEY, ANDREA B (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:B
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2341
Mailing Address - Country:US
Mailing Address - Phone:612-770-2607
Mailing Address - Fax:
Practice Address - Street 1:750 E 34TH ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2341
Practice Address - Country:US
Practice Address - Phone:612-770-2607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46464207Q00000X, 207P00000X
WI62084207P00000X
IA44971207P00000X
SC33012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN724457600Medicaid
MNH96117Medicare UPIN
MN724457600Medicaid