Provider Demographics
NPI:1972595478
Name:STALLINGS, ANDREA MARISA (MS PAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARISA
Last Name:STALLINGS
Suffix:
Gender:F
Credentials:MS PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3444 PRINGLE ST UNIT 9
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1961
Mailing Address - Country:US
Mailing Address - Phone:619-379-0642
Mailing Address - Fax:
Practice Address - Street 1:8851 CENTER DR
Practice Address - Street 2:SUITE 404
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-463-1293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P69423Medicare UPIN