Provider Demographics
NPI:1922384429
Name:ANDERSON, ALLISON BRUCE (PA)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:BRUCE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1838 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6611
Mailing Address - Country:US
Mailing Address - Phone:770-995-7622
Mailing Address - Fax:770-995-7854
Practice Address - Street 1:5669 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 315
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1786
Practice Address - Country:US
Practice Address - Phone:678-843-6400
Practice Address - Fax:678-843-6405
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003120064BMedicaid
GA003120064CMedicaid
GA003120064AMedicaid
GA003120064BMedicaid