Provider Demographics
NPI:1275844326
Name:DUANE, ANDREA DEPTULA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:DEPTULA
Last Name:DUANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:ROSE
Other - Last Name:DEPTULA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:969 SE CENTRAL PKWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3904
Mailing Address - Country:US
Mailing Address - Phone:772-283-0109
Mailing Address - Fax:772-283-1948
Practice Address - Street 1:969 SE CENTRAL PKWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3904
Practice Address - Country:US
Practice Address - Phone:772-283-0109
Practice Address - Fax:772-283-1948
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9104216OtherSTATE LICENSE #