Provider Demographics
NPI:1386679355
Name:DOUYARD, ANDREA (PA C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DOUYARD
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 ROSELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-1411
Mailing Address - Country:US
Mailing Address - Phone:203-574-4747
Mailing Address - Fax:203-574-2251
Practice Address - Street 1:179 ROSELAND AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710
Practice Address - Country:US
Practice Address - Phone:203-574-4747
Practice Address - Fax:203-574-2251
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPENDINGOtherRAILROAD MEDICARE
CT008036775Medicaid
CT1186042OtherUSA
CTD400087932Medicare PIN