Provider Demographics
NPI:1295780898
Name:ANDERSON, ALEXANDER (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0779
Mailing Address - Country:US
Mailing Address - Phone:989-362-9411
Mailing Address - Fax:989-362-9925
Practice Address - Street 1:1015 S WASHINGTON AVE STE E
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601
Practice Address - Country:US
Practice Address - Phone:989-907-7636
Practice Address - Fax:989-907-7584
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMA0951764207P00000X
MI5601003038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003038OtherMI LICENSE
MIP29950018Medicare PIN
MIMI1609012Medicare PIN
MIN8524006Medicare PIN
MIG27604066Medicare PIN
MI5601003038OtherMI LICENSE