Provider Demographics
NPI: | 1467496414 |
---|---|
Name: | ANDERSON, ELIZABETH K (PA-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | ELIZABETH |
Middle Name: | K |
Last Name: | ANDERSON |
Suffix: | |
Gender: | F |
Credentials: | PA-C |
Other - Prefix: | |
Other - First Name: | ELISABETH |
Other - Middle Name: | K |
Other - Last Name: | CLINTON |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | PA |
Mailing Address - Street 1: | 49 SPRING ST |
Mailing Address - Street 2: | |
Mailing Address - City: | SCARBOROUGH |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04074-8926 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 207-885-4479 |
Mailing Address - Fax: | 207-883-2586 |
Practice Address - Street 1: | 49 SPRING ST |
Practice Address - Street 2: | |
Practice Address - City: | SCARBOROUGH |
Practice Address - State: | ME |
Practice Address - Zip Code: | 04074-8926 |
Practice Address - Country: | US |
Practice Address - Phone: | 207-885-4479 |
Practice Address - Fax: | 207-883-2586 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-16 |
Last Update Date: | 2008-06-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ME | PA-832 | 363AS0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ME | 404850099 | Medicaid | |
ME | S30199 | Medicare UPIN | |
ME | 404850099 | Medicaid | |
ME | P00474277 | Medicare PIN | |
ME | AP2146 | Medicare PIN |