Provider Demographics
NPI:1154829992
Name:ANDERSON, JASON BRODY
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BRODY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 HANSON LOOP
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:WA
Mailing Address - Zip Code:99323-8537
Mailing Address - Country:US
Mailing Address - Phone:480-593-6690
Mailing Address - Fax:
Practice Address - Street 1:888 SWIFT BLVD # 180
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:480-593-6690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60825692163W00000X
WAAP60842975367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse