Provider Demographics
NPI:1023057056
Name:ANDERSON, LARRY E (PA-C)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:E
Last Name:ANDERSON
Suffix:
Gender:M
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 1:2840 CROOKS RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-3619
Mailing Address - Country:US
Mailing Address - Phone:248-852-9290
Mailing Address - Fax:248-852-0305
Practice Address - Street 1:2840 CROOKS RD
Practice Address - Street 2:SUITE 111
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3619
Practice Address - Country:US
Practice Address - Phone:248-852-9290
Practice Address - Fax:248-852-0305
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001421363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601001421OtherPA LICENSE