Provider Demographics
NPI:1801275797
Name:HASTINGS, ANDREA ANTONIETA (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:ANTONIETA
Last Name:HASTINGS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:ANTONIETA
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:619 MIDFLORIDA DR STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4916
Mailing Address - Country:US
Mailing Address - Phone:863-701-7188
Mailing Address - Fax:863-701-2014
Practice Address - Street 1:619 MIDFLORIDA DR STE 1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-4916
Practice Address - Country:US
Practice Address - Phone:863-701-7188
Practice Address - Fax:863-701-2014
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-25
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME145759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106832400Medicaid