Provider Demographics
NPI:1184265092
Name:PERRY, ANDREW EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:EDWARD
Last Name:PERRY
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 1:1181 N MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-2574
Mailing Address - Country:US
Mailing Address - Phone:909-639-8800
Mailing Address - Fax:
Practice Address - Street 1:395 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3025
Practice Address - Country:US
Practice Address - Phone:909-639-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58917363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant