Provider Demographics
NPI:1407824030
Name:STANDLEY, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:STANDLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 ALI DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5191
Mailing Address - Country:US
Mailing Address - Phone:810-695-9996
Mailing Address - Fax:
Practice Address - Street 1:3452 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7334
Practice Address - Country:US
Practice Address - Phone:810-606-7550
Practice Address - Fax:810-606-6235
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP30547Medicare UPIN
MI0N33470096Medicare ID - Type Unspecified