Provider Demographics
NPI:1962559336
Name:JOHNNIDIS-KLEIN, ANDREA (PA)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:
Last Name:JOHNNIDIS-KLEIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:62 RUGBY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-1841
Mailing Address - Country:US
Mailing Address - Phone:516-992-0322
Mailing Address - Fax:
Practice Address - Street 1:190 E JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2033
Practice Address - Country:US
Practice Address - Phone:516-977-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008393363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical