Provider Demographics
NPI:1992446207
Name:DESTRO, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:DESTRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 S GADSDEN ST UNIT 805
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-2443
Mailing Address - Country:US
Mailing Address - Phone:404-786-2440
Mailing Address - Fax:
Practice Address - Street 1:2626 CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4402
Practice Address - Country:US
Practice Address - Phone:850-325-5911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-02
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
FLAA793367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant