Basic Information
| Provider Information | |||||||||
| NPI: | 1225066053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEDONA | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128044007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187980767 | ||||||||
| FaxNumber: | 5187980815 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128044007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187980767 | ||||||||
| FaxNumber: | 5187980815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 008010 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02352436 | 05 | NY | MEDICAID |