Healthcare Provider Details

I. General information

NPI: 1649279266
Provider Name (Legal Business Name): BRIDGET CORNELL ANDREW PA,MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 ALTO ST LA FAMILIA MEDICAL CENTER
SANTA FE NM
87501-2406
US

IV. Provider business mailing address

1035 ALTO ST LA FAMILIA MEDICAL CENTER
SANTA FE NM
87501-2406
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-4425
  • Fax: 505-982-6280
Mailing address:
  • Phone: 505-982-4425
  • Fax: 505-982-6280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2009-043
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2822
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number566
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005692-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: