Provider Demographics
NPI:1063652881
Name:ANDERSON, KIRSTIN E (PA-C)
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:E
Last Name:ANDERSON
Suffix:
Gender:F
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:PO BOX 816759
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33081-0759
Mailing Address - Country:US
Mailing Address - Phone:305-674-1233
Mailing Address - Fax:954-964-6084
Practice Address - Street 1:4302 ALTON RD
Practice Address - Street 2:SUITE 830
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2891
Practice Address - Country:US
Practice Address - Phone:305-674-2950
Practice Address - Fax:305-674-2842
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104911363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001067900Medicaid
FLBN682ZMedicare PIN