Provider Demographics
NPI:1235186776
Name:LOVE, ANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDRA
Middle Name:
Last Name:LOVE
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 1:211 LOCKNELL RD
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093
Mailing Address - Country:US
Mailing Address - Phone:410-560-3639
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP86447Medicare UPIN