=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235186776
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRA LOVE P.A.-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2006
-----------------------------------------------------
Last Update Date | 01/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4940 EASTERN AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21224-2735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-550-0483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 LOCKNELL RD
-----------------------------------------------------
City | TIMONIUM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-560-3639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | C02600
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------