Provider Demographics
NPI:1750369021
Name:MCINTOSH, ANDREA REGINA (PA)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:REGINA
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1872 MONTREAL RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5709
Mailing Address - Country:US
Mailing Address - Phone:770-496-9400
Mailing Address - Fax:770-496-9495
Practice Address - Street 1:5669 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE #210
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1786
Practice Address - Country:US
Practice Address - Phone:404-255-4333
Practice Address - Fax:404-255-0601
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2010-05-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA4520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ13424Medicare UPIN
GA97WCGSSMedicare ID - Type Unspecified