Provider Demographics
NPI:1578267191
Name:WHARTON, ANDRE T
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:T
Last Name:WHARTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 NW 70TH AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-7573
Mailing Address - Country:US
Mailing Address - Phone:754-800-1426
Mailing Address - Fax:
Practice Address - Street 1:499 NW 70TH AVE STE 204
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-7573
Practice Address - Country:US
Practice Address - Phone:754-800-1426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory