Provider Demographics
NPI:1366476400
Name:DECKER, ANDREA LEIGH
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:LEIGH
Last Name:DECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 COBBLESTONE CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:FAHC EMERGENCY DEPARTMENT
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-1237
Practice Address - Fax:802-847-5963
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026780363A00000X
VT55-0030650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000163Medicaid
VTAP1989Medicare ID - Type Unspecified
VT9000163Medicaid