Provider Demographics
NPI:1396374799
Name:ANDERSON, ROBERT MICHAEL
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
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 1:3361 LOS NOGALES RD
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-1102
Mailing Address - Country:US
Mailing Address - Phone:805-551-7105
Mailing Address - Fax:
Practice Address - Street 1:10630 SEPULVEDA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1937
Practice Address - Country:US
Practice Address - Phone:818-933-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA58379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program