Provider Demographics
NPI:1487612529
Name:PROVAN, ANDREA Y (CRNP)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:Y
Last Name:PROVAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4663 ROUTE 9G
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12526-5128
Mailing Address - Country:US
Mailing Address - Phone:518-537-7678
Mailing Address - Fax:
Practice Address - Street 1:30 CAMPUS RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12504-9800
Practice Address - Country:US
Practice Address - Phone:845-758-7433
Practice Address - Fax:845-758-7437
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily