Provider Demographics
NPI:1104195833
Name:ANDERSON, KATIE L (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:L
Other - Last Name:SANDLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1421 LOWES WAY
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06374-1963
Mailing Address - Country:US
Mailing Address - Phone:860-317-4000
Mailing Address - Fax:860-317-4030
Practice Address - Street 1:1421 LOWES WAY
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:CT
Practice Address - Zip Code:06374-1963
Practice Address - Country:US
Practice Address - Phone:860-317-4000
Practice Address - Fax:860-317-4030
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2087363A00000X
CT3930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant