Provider Demographics
NPI:1508098765
Name:MEDEL, ANDREA R (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:MEDEL
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 1:1 BAY ST
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1505
Mailing Address - Country:US
Mailing Address - Phone:973-429-6200
Mailing Address - Fax:
Practice Address - Street 1:1 BAY ST
Practice Address - Street 2:
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-1505
Practice Address - Country:US
Practice Address - Phone:973-429-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00221300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant