Provider Demographics
NPI:1336579374
Name:SELIG, ANDREW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:SELIG
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 1:1673 MASON AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5516
Mailing Address - Country:US
Mailing Address - Phone:386-274-7118
Mailing Address - Fax:386-274-6173
Practice Address - Street 1:1673 MASON AVE STE 305
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5516
Practice Address - Country:US
Practice Address - Phone:386-274-7118
Practice Address - Fax:386-274-6173
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107633363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010037100Medicaid