Provider Demographics
NPI:1639530199
Name:BORDELON, ANDREW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:BORDELON
Suffix:
Gender:M
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 1:650 JOEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-798-8400
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD BLDG 9250
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:850-885-2174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1133017363A00000X
FL1133017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant