Provider Demographics
NPI:1952841637
Name:PROCTOR, ANDREW JOSEPH
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:JOSEPH
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ANDREW
Other - Middle Name:JOSEPH
Other - Last Name:PROCTOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:800 PHEASANT WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-5224
Mailing Address - Country:US
Mailing Address - Phone:734-812-1311
Mailing Address - Fax:
Practice Address - Street 1:800 PHEASANT WOODS DRIVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-5224
Practice Address - Country:US
Practice Address - Phone:734-812-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267973367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered