Provider Demographics
NPI:1275559809
Name:MOLL, ANDREA LEIGH (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEIGH
Last Name:MOLL
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 1:16527 JUNIPER PASS
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IN
Mailing Address - Zip Code:46743-7519
Mailing Address - Country:US
Mailing Address - Phone:260-341-7248
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7001
Practice Address - Fax:260-407-8004
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2010-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10000817363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q56193Medicare UPIN
IN142520AAAMedicare ID - Type Unspecified
IN138420A7Medicare ID - Type Unspecified