Provider Demographics
NPI:1124251848
Name:ANDERSON, WAYNE C (ND, PA)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:ND, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3471 REGIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8209
Mailing Address - Country:US
Mailing Address - Phone:707-575-5180
Mailing Address - Fax:707-575-5509
Practice Address - Street 1:3471 REGIONAL PKWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-8209
Practice Address - Country:US
Practice Address - Phone:707-575-5180
Practice Address - Fax:707-575-5509
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA11839363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant