Provider Demographics
NPI:1780380386
Name:ANDERSON, KRISTOPHER
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 FRAZER AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44703-1335
Mailing Address - Country:US
Mailing Address - Phone:412-499-0616
Mailing Address - Fax:
Practice Address - Street 1:1621 FRAZER AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44703-1335
Practice Address - Country:US
Practice Address - Phone:412-499-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH119944377-00Medicaid
OH119944377-00OtherINSURANCE