Provider Demographics
NPI:1346284320
Name:ANDERSON, DEBRA MAE (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:MAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 E HARNEY ST SUITE 100
Mailing Address - Street 2:LARAMIE PHYSICIANS FOR CHILDREN
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2884
Mailing Address - Country:US
Mailing Address - Phone:307-721-3118
Mailing Address - Fax:307-721-4880
Practice Address - Street 1:2710 E HARNEY ST SUITE 100
Practice Address - Street 2:LARAMIE PHYSICIANS FOR CHILDREN
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2884
Practice Address - Country:US
Practice Address - Phone:307-721-3118
Practice Address - Fax:307-721-4880
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5481A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110108100Medicaid
WY303708Medicare ID - Type Unspecified
WYF94358Medicare UPIN