Provider Demographics
NPI:1104708254
Name:NAN, ANDY
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:NAN
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 1:209 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-1221
Mailing Address - Country:US
Mailing Address - Phone:347-384-0521
Mailing Address - Fax:
Practice Address - Street 1:9425 60TH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5069
Practice Address - Country:US
Practice Address - Phone:718-760-0797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant