Provider Demographics
NPI:1295093912
Name:ANDERSON, DESIREE (IDMT)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:
Other - Last Name:LASTRAPES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:208 W CASABLANCA AVE
Mailing Address - Street 2:
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103-5009
Mailing Address - Country:US
Mailing Address - Phone:850-217-8587
Mailing Address - Fax:
Practice Address - Street 1:208 W CASABLANCA AVE
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103-5009
Practice Address - Country:US
Practice Address - Phone:850-217-8587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians