Provider Demographics
NPI:1689236002
Name:KOERNER, ANDREA ROSE (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ROSE
Last Name:KOERNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:THELEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1180 E TWINBROOK DR
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-8319
Mailing Address - Country:US
Mailing Address - Phone:989-640-5513
Mailing Address - Fax:
Practice Address - Street 1:1650 RAMBLEWOOD DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-7396
Practice Address - Country:US
Practice Address - Phone:517-332-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601010497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant