Provider Demographics
NPI:1437567039
Name:COY, ANDREA (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:COY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E BROADWAY ST
Mailing Address - Street 2:BOX 236
Mailing Address - City:WETUMKA
Mailing Address - State:OK
Mailing Address - Zip Code:74883-4505
Mailing Address - Country:US
Mailing Address - Phone:405-452-3151
Mailing Address - Fax:
Practice Address - Street 1:120 E BROADWAY ST
Practice Address - Street 2:BOX 236
Practice Address - City:WETUMKA
Practice Address - State:OK
Practice Address - Zip Code:74883-4505
Practice Address - Country:US
Practice Address - Phone:405-452-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-27
Last Update Date:2014-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant