Provider Demographics
NPI:1831594688
Name:ANDRE, MITSU (PA-C)
Entity type:Individual
Prefix:
First Name:MITSU
Middle Name:
Last Name:ANDRE
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 1:2000 SW ARCHER RD FL 3
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1136
Mailing Address - Country:US
Mailing Address - Phone:352-265-8240
Mailing Address - Fax:352-627-4172
Practice Address - Street 1:2000 SW ARCHER RD FL 3
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1136
Practice Address - Country:US
Practice Address - Phone:352-265-8240
Practice Address - Fax:352-627-4172
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013852800Medicaid
FL013852800Medicaid