Provider Demographics
NPI:1508465139
Name:JUAREZ, ANDREA (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MARKET DR
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-6917
Mailing Address - Country:US
Mailing Address - Phone:631-745-2692
Mailing Address - Fax:
Practice Address - Street 1:9712 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2243
Practice Address - Country:US
Practice Address - Phone:718-830-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024776363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty