Provider Demographics
NPI:1093092926
Name:ANDERSON, MARY RUTH (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RUTH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1334
Mailing Address - Country:US
Mailing Address - Phone:806-796-3000
Mailing Address - Fax:806-796-3006
Practice Address - Street 1:6826 PLUM CREEK DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79124-1601
Practice Address - Country:US
Practice Address - Phone:806-322-3000
Practice Address - Fax:806-322-3006
Is Sole Proprietor?:No
Enumeration Date:2011-11-06
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX733590363LF0000X, 363LF0000X
TXAP120985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200444810 AMedicaid
TX288384502Medicaid
NM35539861Medicaid
OK200444810 AMedicaid