Provider Demographics
NPI:1679967368
Name:GEORGE, ANDREA KALEENA (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:KALEENA
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0010
Mailing Address - Fax:225-765-9298
Practice Address - Street 1:4811 AMBASSADOR CAFFERY PKWY STE 305
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7266
Practice Address - Country:US
Practice Address - Phone:337-470-3040
Practice Address - Fax:337-470-3052
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAPA200803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2502498Medicaid
LA405263YJBAMedicare PIN