Provider Demographics
NPI:1003839291
Name:ANDERSEN, BETH (PA)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 SAND PIT RD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4032
Mailing Address - Country:US
Mailing Address - Phone:203-743-7246
Mailing Address - Fax:203-792-3920
Practice Address - Street 1:67 SAND PIT RD
Practice Address - Street 2:SUITE 308
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4032
Practice Address - Country:US
Practice Address - Phone:203-743-7246
Practice Address - Fax:203-792-3920
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010302363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00298878OtherRAILROAD MEDICARE
NY4682510004Medicare NSC
NYP00298878OtherRAILROAD MEDICARE
NY5836LCJ511Medicare PIN
NYQ42826Medicare UPIN
NY4682510003Medicare NSC