Provider Demographics
NPI:1346726999
Name:BLACK, ANDREW (APRN)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8374
Mailing Address - Country:US
Mailing Address - Phone:330-472-1714
Mailing Address - Fax:
Practice Address - Street 1:5041 VICTOR DR STE C
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-6028
Practice Address - Country:US
Practice Address - Phone:330-723-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023120363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.023120OtherSTATE (OHIO) ENDORSEMENT CNP