Provider Demographics
NPI:1932314218
Name:ANDERSON, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
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 1:318 RUHLE RD S
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019
Mailing Address - Country:US
Mailing Address - Phone:518-899-4133
Mailing Address - Fax:518-899-5764
Practice Address - Street 1:318 RUHLE RD S
Practice Address - Street 2:
Practice Address - City:BALLSTON LAKE
Practice Address - State:NY
Practice Address - Zip Code:12019-1030
Practice Address - Country:US
Practice Address - Phone:518-899-4133
Practice Address - Fax:518-899-5764
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004931-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant