Provider Demographics
NPI:1609185669
Name:TAFT, ANDREA LYNN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:LYNN
Last Name:TAFT
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 1:221 VILLA LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2737
Mailing Address - Country:US
Mailing Address - Phone:269-370-4846
Mailing Address - Fax:
Practice Address - Street 1:221 VILLA LN
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2737
Practice Address - Country:US
Practice Address - Phone:269-370-4846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2011-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601095888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant