Basic Information
| Provider Information | |||||||||
| NPI: | 1366846008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDREI | ||||||||
| FirstName: | FABIOLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST | ||||||||
| Address2: | SVC BLD SUITE 303 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295552 | ||||||||
| FaxNumber: | 5026293132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2014 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TC327 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA1910 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100327280 | 05 | KY | MEDICAID | PA1910 | 01 | KY | LICENSE | OTHER |