Healthcare Provider Details

I. General information

NPI: 1073575908
Provider Name (Legal Business Name): ANDREA GENTRY BROCK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 MEDICAL PARK RD SUITE 101
MOORESVILLE NC
28117-8578
US

IV. Provider business mailing address

128 MEDICAL PARK RD SUITE 101
MOORESVILLE NC
28117-8578
US

V. Phone/Fax

Practice location:
  • Phone: 704-658-1001
  • Fax: 704-658-1002
Mailing address:
  • Phone: 704-658-1001
  • Fax: 704-658-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103497
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: