Provider Demographics
NPI:1376570283
Name:HENDRICKS, ANDREA ELIZABETH (PAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ELIZABETH
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5290 LAKEWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 NIAGARA CT
Practice Address - Street 2:UMD HEALTH SERVICES
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-3065
Practice Address - Country:US
Practice Address - Phone:218-726-8155
Practice Address - Fax:218-726-6132
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9308363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S73312Medicare UPIN