Provider Demographics
NPI:1689774788
Name:DIMICHELE-MANES, ANDREA TERESA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:TERESA
Last Name:DIMICHELE-MANES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:TERESA
Other - Last Name:DIMICHELE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3138
Mailing Address - Fax:208-463-3047
Practice Address - Street 1:310 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5572
Practice Address - Country:US
Practice Address - Phone:620-275-9752
Practice Address - Fax:620-275-4306
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200601542207V00000X
KS04-45692207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906092Medicaid