Provider Demographics
NPI:1740823855
Name:MALDONADO, ANDRES (LPN)
Entity type:Individual
Prefix:MR
First Name:ANDRES
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 PEACH ST REAR
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-2409
Mailing Address - Country:US
Mailing Address - Phone:716-400-2305
Mailing Address - Fax:
Practice Address - Street 1:17 PEACH ST REAR
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-2409
Practice Address - Country:US
Practice Address - Phone:716-400-2305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328532-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse