Provider Demographics
NPI:1659522449
Name:CIARAVINO, ANDREA G (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:G
Last Name:CIARAVINO
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 1:19401 HUBBARD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2641
Mailing Address - Country:US
Mailing Address - Phone:313-982-8241
Mailing Address - Fax:
Practice Address - Street 1:HERNY FORD
Practice Address - Street 2:2799 WEST GRAND BLVD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-982-8241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1659522449363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102755Medicaid
NC8102755Medicaid