Provider Demographics
NPI:1568544906
Name:NETTLES, ANDREA J (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:NETTLES
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 1:2001 70TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4628
Mailing Address - Country:US
Mailing Address - Phone:970-378-4155
Mailing Address - Fax:
Practice Address - Street 1:2001 70TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4628
Practice Address - Country:US
Practice Address - Phone:970-378-4155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005029532363AM0700X
KS1501043363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical