Provider Demographics
NPI:1497222525
Name:HOLMGREN, ANDREA MANCUSO (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MANCUSO
Last Name:HOLMGREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:MANCUSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2315 MYRTLE ST STE 160
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-4602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 COAL VALLEY RD STE 504
Practice Address - Street 2:
Practice Address - City:JEFFERSON HILLS
Practice Address - State:PA
Practice Address - Zip Code:15025-3729
Practice Address - Country:US
Practice Address - Phone:814-456-9197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA0601732086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103584336Medicaid