Provider Demographics
NPI:1780200022
Name:ANDERSON, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-1914
Mailing Address - Country:US
Mailing Address - Phone:906-241-7436
Mailing Address - Fax:
Practice Address - Street 1:208 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-1914
Practice Address - Country:US
Practice Address - Phone:906-241-7436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704297360363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily