Provider Demographics
NPI:1821309477
Name:OBERLIN, ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:OBERLIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 W ICE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:IRON RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49935-9526
Mailing Address - Country:US
Mailing Address - Phone:906-265-6121
Mailing Address - Fax:
Practice Address - Street 1:1300 W ICE LAKE RD
Practice Address - Street 2:
Practice Address - City:IRON RIVER
Practice Address - State:MI
Practice Address - Zip Code:49935-8507
Practice Address - Country:US
Practice Address - Phone:906-265-9189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1426 TEMP363AM0700X
MN10755363AM0700X
MI5601007017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970004788Medicare PIN