Provider Demographics
NPI:1881961027
Name:PRIDE, ANDRE LANE (PAC)
Entity type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:LANE
Last Name:PRIDE
Suffix:
Gender:M
Credentials:PAC
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Mailing Address - Street 1:125 S KALAMAZOO MALL STE 204
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-4869
Mailing Address - Country:US
Mailing Address - Phone:866-898-7139
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:300 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3307
Practice Address - Country:US
Practice Address - Phone:269-966-8000
Practice Address - Fax:937-619-4150
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2012-05-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC96159121Medicare PIN