Provider Demographics
NPI:1386651172
Name:ANDERSON, CONNIE L (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
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 1:105 N 31ST AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2940
Mailing Address - Country:US
Mailing Address - Phone:402-346-1111
Mailing Address - Fax:402-408-0004
Practice Address - Street 1:105 N 31ST AVE
Practice Address - Street 2:STE 102
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2940
Practice Address - Country:US
Practice Address - Phone:402-346-1111
Practice Address - Fax:402-408-0004
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE640363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE37956OtherBCBS
970015303OtherRAILROAD MEDICARE
NE810OtherMIDLANDS
NE810OtherMIDLANDS
NE272787Medicare PIN
970015303OtherRAILROAD MEDICARE