Provider Demographics
NPI:1316110430
Name:HARRIS, ANDREA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9016
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:755 W CARMEL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5877
Practice Address - Country:US
Practice Address - Phone:317-846-2396
Practice Address - Fax:317-846-1699
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000832A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN187490IMedicare PIN
INQ60733Medicare UPIN