Provider Demographics
NPI:1104937317
Name:ANDERSON, NANCY A (PA-C)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
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 1:1505 NORTHSIDE BLVD
Mailing Address - Street 2:STE 2400
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7623
Mailing Address - Country:US
Mailing Address - Phone:770-292-3490
Mailing Address - Fax:404-851-6283
Practice Address - Street 1:1505 NORTHSIDE BLVD
Practice Address - Street 2:STE 2400
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7623
Practice Address - Country:US
Practice Address - Phone:770-292-3490
Practice Address - Fax:404-851-6283
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002106363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003119970DMedicaid
GA003119970BMedicaid
GA003119970CMedicaid
GA003119970DMedicaid
R55530Medicare UPIN