Provider Demographics
NPI:1578821393
Name:STUCKER, ANDREA HALE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:HALE
Last Name:STUCKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:
Practice Address - Street 1:875 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2529
Practice Address - Country:US
Practice Address - Phone:502-348-5685
Practice Address - Fax:502-348-1771
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1721363A00000X
KYTC102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100212110Medicaid
KYPA1721OtherMEDICAL LICENSE