Provider Demographics
NPI:1821064601
Name:CARLIN, ANDREA LOUISE (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LOUISE
Last Name:CARLIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LOUISE
Other - Last Name:BYFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1717 E. CHICAGO RD
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091
Mailing Address - Country:US
Mailing Address - Phone:269-651-3554
Mailing Address - Fax:269-659-4998
Practice Address - Street 1:1717 E. CHICAGO RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091
Practice Address - Country:US
Practice Address - Phone:269-651-3554
Practice Address - Fax:269-659-4998
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110G510580OtherBCBS GROUP-INTERNAL MEDICINE
MI700G560080OtherBCBS GROUP - THREE RIVERS HEALTH
MIQ65371Medicare UPIN
MIG56008 128Medicare ID - Type Unspecified
MI230015Medicare Oscar/Certification