Provider Demographics
NPI:1720230998
Name:ANDERSON, CARRIE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:NICOLE
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 1:1300 SAWGRASS CORPORATE PARKWAY
Mailing Address - Street 2:STE 200
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2823
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-527-5510
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-202-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-18
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014299000Medicaid