Provider Demographics
NPI:1205491396
Name:ANDERSON, NIKITA (PROSTHESIS SPECIALIS)
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PROSTHESIS SPECIALIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 8TH ST APT C111
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-3494
Mailing Address - Country:US
Mailing Address - Phone:510-253-7214
Mailing Address - Fax:
Practice Address - Street 1:1122 B ST STE 101
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4237
Practice Address - Country:US
Practice Address - Phone:510-253-7214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-05
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAKK5245261744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty