Provider Demographics
NPI:1578791570
Name:HANSEN, ANDREA LEIGH (PA)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:LEIGH
Last Name:HANSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:LEIGH
Other - Last Name:BREITBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1825 LOGAN AVE
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1916
Mailing Address - Country:US
Mailing Address - Phone:319-235-3697
Mailing Address - Fax:319-235-3844
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3697
Practice Address - Fax:319-235-3844
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant