Provider Demographics
NPI:1700841277
Name:ANDERSON, ROBERT H (PA C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA C
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Mailing Address - Street 1:113 S APPLE ST
Mailing Address - Street 2:
Mailing Address - City:SHOSHONE
Mailing Address - State:ID
Mailing Address - Zip Code:83352-5287
Mailing Address - Country:US
Mailing Address - Phone:208-886-2224
Mailing Address - Fax:208-886-2634
Practice Address - Street 1:425 IDAHO STREET
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330
Practice Address - Country:US
Practice Address - Phone:208-934-5900
Practice Address - Fax:208-934-5719
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2017-08-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-289363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P04479Medicare UPIN