Provider Demographics
NPI:1659027415
Name:ANDERSON, MYISHA
Entity Type:Individual
Prefix:
First Name:MYISHA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 E FERNHURST DR STE 304
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-1586
Mailing Address - Country:US
Mailing Address - Phone:346-361-0010
Mailing Address - Fax:
Practice Address - Street 1:633 E FERNHURST DR STE 304
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-1586
Practice Address - Country:US
Practice Address - Phone:346-361-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25213697363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2547555OtherNONE