Provider Demographics
NPI:1174631642
Name:ANDREWS, JEB (PA)
Entity Type:Individual
Prefix:MR
First Name:JEB
Middle Name:
Last Name:ANDREWS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 BROADMOOR BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3184
Mailing Address - Country:US
Mailing Address - Phone:878-381-3823
Mailing Address - Fax:
Practice Address - Street 1:2509 BROADMOOR BLVD
Practice Address - Street 2:STE B
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:878-381-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP78021Medicare UPIN