Provider Demographics
NPI:1376731570
Name:ANDERSON, NATHANIAL R
Entity Type:Individual
Prefix:
First Name:NATHANIAL
Middle Name:R
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:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:ROUND MOUNTAIN
Mailing Address - State:CA
Mailing Address - Zip Code:96084-0228
Mailing Address - Country:US
Mailing Address - Phone:530-337-5750
Mailing Address - Fax:
Practice Address - Street 1:29632 HWY 299E
Practice Address - Street 2:
Practice Address - City:ROUND MOUNTAIN
Practice Address - State:CA
Practice Address - Zip Code:96084
Practice Address - Country:US
Practice Address - Phone:530-337-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTANDERNOtherSWBHC STAFF CODE