Provider Demographics
NPI:1124330865
Name:ANDERSEN, COLBY J (PA)
Entity type:Individual
Prefix:MR
First Name:COLBY
Middle Name:J
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1511
Mailing Address - Country:US
Mailing Address - Phone:801-393-5355
Mailing Address - Fax:801-394-4609
Practice Address - Street 1:550 E 1400 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2406
Practice Address - Country:US
Practice Address - Phone:435-752-7060
Practice Address - Fax:801-394-4609
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1078363A00000X
COPA3028363A00000X
UT10912261-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO35933330Medicaid