=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184583072
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARVIN NICHOLAS ANDRADE JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2026
-----------------------------------------------------
Last Update Date | 01/17/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3505 VILLAGE DR STE 201
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-4514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-323-0065
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3505 VILLAGE DR STE 201
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-4514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-323-0065
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 200601668
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------