Provider Demographics
NPI:1205822442
Name:ANDERSON, JAMES ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALLEN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 S WASHINGTON ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2951
Mailing Address - Country:US
Mailing Address - Phone:307-577-4220
Mailing Address - Fax:307-235-0931
Practice Address - Street 1:419 S WASHINGTON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2951
Practice Address - Country:US
Practice Address - Phone:307-577-4220
Practice Address - Fax:307-235-0931
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3032A208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0575134Medicaid
MT0069887Medicaid
WY301490OtherBLUE CROSS BLUE SHIELD
WA8359374Medicaid
CO78282241Medicaid
CO78282241Medicaid
WY301490OtherBLUE CROSS BLUE SHIELD