Provider Demographics
NPI:1831557107
Name:BURGESS, ANDREA ALYS (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:ALYS
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ANDREA
Other - Middle Name:ALYS
Other - Last Name:KERRIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:600 BROADWAY
Mailing Address - Street 2:SUITE 460
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122
Mailing Address - Country:US
Mailing Address - Phone:206-320-2078
Mailing Address - Fax:
Practice Address - Street 1:600 BROADWAY SWEDISH MAXILLOFACIAL SURGERY
Practice Address - Street 2:SUITE 460
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122
Practice Address - Country:US
Practice Address - Phone:206-320-2078
Practice Address - Fax:206-386-3296
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA60800587363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1831557107Medicaid