Provider Demographics
NPI:1396920658
Name:ANDERSON, JOY A (DPM)
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3247
Mailing Address - Country:US
Mailing Address - Phone:904-261-3653
Mailing Address - Fax:904-261-7790
Practice Address - Street 1:1325 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:FERNANDINA
Practice Address - State:FL
Practice Address - Zip Code:32034-3247
Practice Address - Country:US
Practice Address - Phone:904-261-3653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3335213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6371320001OtherMEDICARE PTAN
FL6371320001OtherMEDICARE PTAN