Provider Demographics
NPI:1437255924
Name:MCCOUBREY, ANDREW T (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:T
Last Name:MCCOUBREY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 CONNABLE AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2212
Mailing Address - Country:US
Mailing Address - Phone:231-487-7129
Mailing Address - Fax:231-487-3082
Practice Address - Street 1:416 CONNABLE AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2212
Practice Address - Country:US
Practice Address - Phone:231-487-7129
Practice Address - Fax:231-487-3082
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003666363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q03523Medicare UPIN
MI0M76280Medicare PIN