Provider Demographics
NPI:1649052416
Name:BANDY, LEE IVY (PA-C)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:IVY
Last Name:BANDY
Suffix:
Gender:F
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-793-0106
Mailing Address - Fax:
Practice Address - Street 1:8105 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-3905
Practice Address - Country:US
Practice Address - Phone:443-573-0564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant