Provider Demographics
NPI:1396148326
Name:ANDAZOLA, JIMMY F (PA-C)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:F
Last Name:ANDAZOLA
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 1:10571 VISTA BELLA PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3875
Mailing Address - Country:US
Mailing Address - Phone:505-259-1133
Mailing Address - Fax:
Practice Address - Street 1:10571 VISTA BELLA PL NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-3875
Practice Address - Country:US
Practice Address - Phone:505-259-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-05
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7337363A00000X
NMPA2014-0051363A00000X, 363AM0700X
OK4505363A00000X
SC3518363AM0700X
GA10494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical