Provider Demographics
NPI:1821601493
Name:MCGANNON, ANDREA N (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:N
Last Name:MCGANNON
Suffix:
Gender:F
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 1:3634 NW ADRIATIC LN
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-3111
Mailing Address - Country:US
Mailing Address - Phone:440-391-7017
Mailing Address - Fax:
Practice Address - Street 1:2100 SE SALERNO RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6503
Practice Address - Country:US
Practice Address - Phone:772-781-2735
Practice Address - Fax:772-781-2739
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9116067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program