Provider Demographics
NPI:1740382472
Name:MCINTOSH, ANDREA A (PA)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:A
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555S VOLUSIA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9116
Mailing Address - Country:US
Mailing Address - Phone:386-774-0401
Mailing Address - Fax:386-774-5783
Practice Address - Street 1:2575 S VOLUSIA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-9135
Practice Address - Country:US
Practice Address - Phone:386-774-0401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102239363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291511100Medicaid
FL291511100Medicaid