Provider Demographics
NPI:1306412754
Name:ALI, ANDREA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:NICOLE
Last Name:ALI
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ANDREA
Other - Middle Name:NICOLE
Other - Last Name:KRAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35213 DATE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-3130
Mailing Address - Country:US
Mailing Address - Phone:909-380-3582
Mailing Address - Fax:
Practice Address - Street 1:24785 STEWART ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1721
Practice Address - Country:US
Practice Address - Phone:909-558-7295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant