Provider Demographics
NPI:1235451584
Name:ANDERSON, TASHA MONIQUE (PA-C)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:MONIQUE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 BELLEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-6946
Mailing Address - Country:US
Mailing Address - Phone:347-432-7522
Mailing Address - Fax:
Practice Address - Street 1:4300 BELAIR RD STE A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-6300
Practice Address - Country:US
Practice Address - Phone:410-325-2100
Practice Address - Fax:410-630-5130
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC05296OtherMARYLAND LICENSE