Provider Demographics
NPI:1326550872
Name:MANTLE, ANDREA MAUREEN (LSA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MAUREEN
Last Name:MANTLE
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 FM 718
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:TX
Mailing Address - Zip Code:76078-5213
Mailing Address - Country:US
Mailing Address - Phone:940-206-1069
Mailing Address - Fax:214-764-0880
Practice Address - Street 1:1901 FM 718
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:TX
Practice Address - Zip Code:76078-5213
Practice Address - Country:US
Practice Address - Phone:940-206-1069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
TXSA00830246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty