Basic Information
| Provider Information | |||||||||
| NPI: | 1639132129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONKLE | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | DONN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 FRANTZ RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145446356 | ||||||||
| FaxNumber: | 6145446370 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 E STATE ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145667370 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 50.001081 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0094443 | 05 | OH | MEDICAID |