Provider Demographics
NPI:1982640025
Name:STURDIVANT, ANDREW L (PA C)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:L
Last Name:STURDIVANT
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 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4896
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:700 NE 87TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1771
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004664363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0185019OtherLIWA
WA2167STOtherBSWA
WA8803039Medicaid
WA0185018OtherLIWA
WA8393381Medicaid
WA2164STOtherBSWA
WA0185017OtherLIWA
WA1186STOtherBSWA
WA8393039Medicaid
WA8393381Medicaid
WA8393039Medicaid
WAG8850860Medicare PIN
WAG8803037Medicare PIN