Provider Demographics
NPI:1669005195
Name:ANDERSON, RAVEN (PA-C)
Entity Type:Individual
Prefix:
First Name:RAVEN
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 82969
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-2969
Mailing Address - Country:US
Mailing Address - Phone:813-866-0930
Mailing Address - Fax:
Practice Address - Street 1:4620 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-6205
Practice Address - Country:US
Practice Address - Phone:813-397-5300
Practice Address - Fax:813-247-5591
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant