Provider Demographics
NPI:1003922790
Name:ANDERSON, CLINTON S (PA-C)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:M
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 1:269 MORGAN'S ROAD
Mailing Address - Street 2:
Mailing Address - City:ANIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99557-0269
Mailing Address - Country:US
Mailing Address - Phone:907-675-4556
Mailing Address - Fax:907-675-4687
Practice Address - Street 1:269 MORGAN'S ROAD
Practice Address - Street 2:
Practice Address - City:ANIAK
Practice Address - State:AK
Practice Address - Zip Code:99557-0269
Practice Address - Country:US
Practice Address - Phone:907-675-4556
Practice Address - Fax:907-675-4687
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375970-1206363A00000X
AK1027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTMA1469368OtherDEA
UTMA1469368OtherDEA