Provider Demographics
NPI:1639453640
Name:VANDAM, ANDREA LEIGH (PA)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:LEIGH
Last Name:VANDAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 MEDICAL WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-5412
Mailing Address - Country:US
Mailing Address - Phone:863-382-0770
Mailing Address - Fax:863-471-9968
Practice Address - Street 1:3201 MEDICAL WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-5412
Practice Address - Country:US
Practice Address - Phone:863-382-0770
Practice Address - Fax:863-471-9968
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPAX00009111OtherPRESCRIBING LICENSE
FL004133400Medicaid