Provider Demographics
NPI:1093782542
Name:ANDERS, LYDIA J (R PAC)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:J
Last Name:ANDERS
Suffix:
Gender:F
Credentials:R PAC
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 2003
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4503
Mailing Address - Country:US
Mailing Address - Phone:315-446-3904
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:5700 W GENESEE ST
Practice Address - Street 2:SUITE 132
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-3200
Practice Address - Country:US
Practice Address - Phone:315-487-5858
Practice Address - Fax:315-487-1950
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010011363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGMedicare UPIN