Provider Demographics
NPI:1477824472
Name:PITZL, ANDREA JO (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:JO
Last Name:PITZL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:JO
Other - Last Name:SHAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3208 36TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1713
Mailing Address - Country:US
Mailing Address - Phone:612-805-5015
Mailing Address - Fax:
Practice Address - Street 1:3208 36TH AVE NE
Practice Address - Street 2:
Practice Address - City:ST ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-1713
Practice Address - Country:US
Practice Address - Phone:612-805-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11081363AS0400X
MN1668363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP01138670OtherRAILROAD MEDICARE
MN970005940Medicare PIN