Provider Demographics
NPI:1134568850
Name:ANDERSON, EMILY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
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 1:10351 DAWSONS CREEK BLVD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1904
Mailing Address - Country:US
Mailing Address - Phone:260-203-9600
Mailing Address - Fax:260-739-6167
Practice Address - Street 1:4403 HARRISON BLVD STE 3490
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3284
Practice Address - Country:US
Practice Address - Phone:801-442-3256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-15
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001527A363A00000X
UT10001527A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN692190012Medicare PIN