Provider Demographics
NPI:1154896058
Name:ANDERSON, JAMIE LEE (PA-C)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LEE
Other - Last Name:BOMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2940 E. BANNER GATWAY DR
Mailing Address - Street 2:SUITE 450
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:480-256-3682
Practice Address - Street 1:2946 E BANNER GATEWAY DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-3682
Is Sole Proprietor?:No
Enumeration Date:2018-10-06
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7301363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical