Provider Demographics
NPI:1144284654
Name:REQUA, ANDREA MARIE (DO)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:REQUA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 758952
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8952
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:5125 JONESTOWN RD STE 105
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-2987
Practice Address - Country:US
Practice Address - Phone:717-943-1566
Practice Address - Fax:717-943-1567
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007422E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA720614YUMNMedicare PIN
PAF26587Medicare UPIN
PA720614YEBKMedicare PIN