Provider Demographics
NPI:1790011724
Name:BLACK, ANDREW P (PA - C)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:P
Last Name:BLACK
Suffix:
Gender:M
Credentials:PA - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6438 WILMINGTON PIKE STE 110
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7021
Mailing Address - Country:US
Mailing Address - Phone:937-848-4121
Mailing Address - Fax:937-848-5965
Practice Address - Street 1:6438 WILMINGTON PIKE STE 110
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-7021
Practice Address - Country:US
Practice Address - Phone:937-848-4121
Practice Address - Fax:937-848-5965
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50-002937363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000636013OtherBCBS-OH
OH000000636013OtherBCBS-OH