Basic Information
Provider Information | |||||||||
NPI: | 1114959038 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDREWS | ||||||||
FirstName: | JUDY | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MASON | ||||||||
OtherFirstName: | JUDY | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 346 GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 137902580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077298156 | ||||||||
FaxNumber: | 6077292209 | ||||||||
Practice Location | |||||||||
Address1: | 1302 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ENDICOTT | ||||||||
State: | NY | ||||||||
PostalCode: | 137605430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077547171 | ||||||||
FaxNumber: | 6077540290 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 11/23/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 010403 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 02858157 | 05 | NY |   | MEDICAID |