Healthcare Provider Details

I. General information

NPI: 1386385706
Provider Name (Legal Business Name): ANDREA MASHAYEKHI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE STE 101
CHARLESTON WV
25304-1215
US

IV. Provider business mailing address

119 S BROOKE DR
HURRICANE WV
25526-9070
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-8200
  • Fax: 304-388-7010
Mailing address:
  • Phone: 304-993-7419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: