Provider Demographics
NPI:1487640165
Name:ANDERSON, PATRICK (RPA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 SHERMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819
Mailing Address - Country:US
Mailing Address - Phone:802-748-9405
Mailing Address - Fax:802-748-4540
Practice Address - Street 1:185 SHERMAN DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9811
Practice Address - Country:US
Practice Address - Phone:802-748-5041
Practice Address - Fax:802-748-5094
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010315-1363A00000X
VT055.0031225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1500OtherMEDICARE GROUP ID
NY02596885Medicaid
NYAA1500OtherMEDICARE GROUP ID
Q28500Medicare UPIN