Provider Demographics
NPI:1497710792
Name:BLAKE-MCMAHON, ANDREA NATALIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:NATALIE
Last Name:BLAKE-MCMAHON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:NATLALIE
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1007 GOULD DR
Mailing Address - Street 2:STE 1
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-4971
Mailing Address - Country:US
Mailing Address - Phone:318-377-2007
Mailing Address - Fax:318-377-3099
Practice Address - Street 1:129 MINDEN SHOPPING DR
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-2770
Practice Address - Country:US
Practice Address - Phone:318-377-2007
Practice Address - Fax:318-377-3099
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14851R207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1150185Medicaid
H84202Medicare UPIN
LA1150185Medicaid