Provider Demographics
NPI:1740233444
Name:EARLE-RICHARDSON, ANDREW F
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:F
Last Name:EARLE-RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1110
Mailing Address - Country:US
Mailing Address - Phone:404-778-0118
Mailing Address - Fax:
Practice Address - Street 1:2200 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1110
Practice Address - Country:US
Practice Address - Phone:404-778-0118
Practice Address - Fax:404-351-7762
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02147208Medicaid
NY78800LMedicare ID - Type UnspecifiedUPSTATE
NYS40222Medicare UPIN