Provider Demographics
NPI:1427023621
Name:CARRASCO, ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-1203
Mailing Address - Country:US
Mailing Address - Phone:518-883-8620
Mailing Address - Fax:518-883-4960
Practice Address - Street 1:4104 STATE HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:PERTH
Practice Address - State:NY
Practice Address - Zip Code:12010-6202
Practice Address - Country:US
Practice Address - Phone:518-883-8620
Practice Address - Fax:518-773-4960
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225251207Q00000X
OR192744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02278751Medicaid
NY02278751Medicaid
OR500763850Medicaid
NYDD1633Medicare ID - Type Unspecified