Provider Demographics
NPI:1427009471
Name:ANDERSON, ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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:PO BOX 10668
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-5668
Mailing Address - Country:US
Mailing Address - Phone:631-422-6166
Mailing Address - Fax:631-422-6266
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-384-9437
Practice Address - Fax:704-384-9440
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03380363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010580OtherNY LICENSE NUMBER
NC0010-03380OtherNC LICENSE