Healthcare Provider Details

I. General information

NPI: 1184413155
Provider Name (Legal Business Name): ANDREW JAMES MIDLAND PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

783 CARSON CIR
GROTTOES VA
24441-2581
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1288
  • Fax:
Mailing address:
  • Phone: 757-630-1366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010910
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: