Provider Demographics
NPI:1023084019
Name:GROOMS, ANDREA LYNNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LYNNE
Last Name:GROOMS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ANDREA
Other - Middle Name:DRAKE
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:570 W. SAM RIDLEY PRKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167
Mailing Address - Country:US
Mailing Address - Phone:615-984-2940
Mailing Address - Fax:614-984-2945
Practice Address - Street 1:570 W. SAM RIDLEY PRKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167
Practice Address - Country:US
Practice Address - Phone:615-984-2940
Practice Address - Fax:614-984-2945
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000860363A00000X
PAMA051040363A00000X, 363AM0700X
TN5109363A00000X, 363AM0700X
PAOA003670363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1023084019Medicaid
DE1023084019Medicaid
DE275095ZATAMedicare PIN
P89432Medicare UPIN