Provider Demographics
NPI:1184047730
Name:ANDERSON, TODD CHRISTOPHER (APRN)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:CHRISTOPHER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:105 JACKSON STREET
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3058
Practice Address - Country:US
Practice Address - Phone:501-941-3522
Practice Address - Fax:501-941-3525
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARATP-000613363LF0000X
ARA004077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR202081758Medicaid