Provider Demographics
NPI:1821852203
Name:BLISS, ANDREW CHARLES
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:CHARLES
Last Name:BLISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CENTINELA AVE STE 5-M1024
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-1076
Mailing Address - Country:US
Mailing Address - Phone:310-902-0538
Mailing Address - Fax:
Practice Address - Street 1:2707 E VALLEY BLVD STE 116
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-3196
Practice Address - Country:US
Practice Address - Phone:626-581-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF12230868363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily