Provider Demographics
NPI:1639132129
Name:CONKLE, ANDREW DONN (PA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DONN
Last Name:CONKLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 FRANTZ RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4144
Mailing Address - Country:US
Mailing Address - Phone:614-544-6356
Mailing Address - Fax:614-544-6370
Practice Address - Street 1:285 E STATE ST
Practice Address - Street 2:SUITE 400
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4354
Practice Address - Country:US
Practice Address - Phone:614-566-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.001081363AS0400X
OH5001081363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094443Medicaid
H218761Medicare PIN