Healthcare Provider Details

I. General information

NPI: 1144284654
Provider Name (Legal Business Name): ANDREA MARIE REQUA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5125 JONESTOWN RD STE 105
HARRISBURG PA
17112-2987
US

IV. Provider business mailing address

PO BOX 758952
BALTIMORE MD
21275-8952
US

V. Phone/Fax

Practice location:
  • Phone: 717-943-1566
  • Fax: 717-943-1567
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS007422E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: