Provider Demographics
NPI:1053038976
Name:DEETJEEN, ANDY
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:DEETJEEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 NW 62ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33150-4332
Mailing Address - Country:US
Mailing Address - Phone:786-655-0529
Mailing Address - Fax:
Practice Address - Street 1:2451 NW 41ST AVE APT 408
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313-3769
Practice Address - Country:US
Practice Address - Phone:646-830-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant