Provider Demographics
NPI:1942356944
Name:ANDERSON, ALEATHEA RAE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ALEATHEA
Middle Name:RAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:20 SE NINTH STREET
Mailing Address - Street 2:CENTRACARE HEALTH SYSTEM-LONG PRAIRIE
Mailing Address - City:LONG PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56347-1404
Mailing Address - Country:US
Mailing Address - Phone:320-732-2141
Mailing Address - Fax:320-732-6913
Practice Address - Street 1:20 SE NINTH STREET
Practice Address - Street 2:CENTRACARE HEALTH SYSTEM-LONG PRAIRIE
Practice Address - City:LONG PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56347-1404
Practice Address - Country:US
Practice Address - Phone:320-732-2141
Practice Address - Fax:320-732-6913
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2089363AM0700X
MN10212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970005182Medicare PIN