Provider Demographics
NPI:1467451203
Name:ANDERSON, STEVEN ERIC (PA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:ERIC
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:
Practice Address - Street 1:1917 W PARK DR
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3585
Practice Address - Country:US
Practice Address - Phone:336-903-7845
Practice Address - Fax:336-903-7841
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3125363A00000X, 363AM0700X, 363AS0400X
NC100443363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC9073AOtherMEDICARE PTAN, INDIVIDUAL AT WILKES
FLE0645Medicare ID - Type Unspecified
FLR40103Medicare UPIN
NC230063SMedicare PIN
NCNC9073AOtherMEDICARE PTAN, INDIVIDUAL AT WILKES