Provider Demographics
NPI:1124508460
Name:SCHRECONGOST, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:SCHRECONGOST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:LANGOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3760 STATE RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4063
Mailing Address - Country:US
Mailing Address - Phone:810-841-8909
Mailing Address - Fax:
Practice Address - Street 1:5525 S MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911
Practice Address - Country:US
Practice Address - Phone:517-913-3888
Practice Address - Fax:517-394-7483
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant