Provider Demographics
NPI:1659509628
Name:ANDOLA, CHARLES MICHAEL III (MS, PA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:ANDOLA
Suffix:III
Gender:M
Credentials:MS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 AIRPORT EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-5238
Mailing Address - Country:US
Mailing Address - Phone:845-262-5313
Mailing Address - Fax:845-426-6126
Practice Address - Street 1:350 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-3049
Practice Address - Country:US
Practice Address - Phone:845-634-7500
Practice Address - Fax:845-634-7566
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002281363A00000X
NY013344-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400123228OtherMEDICARE