Provider Demographics
NPI:1689743460
Name:ANDERSON, MICHAEL ANGELO (EMT-P)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANGELO
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:EMT-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 SCENIC ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-6226
Mailing Address - Country:US
Mailing Address - Phone:352-303-6143
Mailing Address - Fax:352-728-3719
Practice Address - Street 1:618 SCENIC ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6226
Practice Address - Country:US
Practice Address - Phone:352-303-6143
Practice Address - Fax:352-728-3719
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMD510306171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor