Provider Demographics
NPI:1154441731
Name:ANDAL, IEDA (PA)
Entity Type:Individual
Prefix:MRS
First Name:IEDA
Middle Name:
Last Name:ANDAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E ANGELENO AVE
Mailing Address - Street 2:UNIT 125
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-2947
Mailing Address - Country:US
Mailing Address - Phone:818-321-8349
Mailing Address - Fax:
Practice Address - Street 1:13356 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-3200
Practice Address - Country:US
Practice Address - Phone:818-362-6182
Practice Address - Fax:818-367-2340
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14668363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant