Provider Demographics
NPI:1194553826
Name:ANDERSON, TEQUILA (NP)
Entity type:Individual
Prefix:
First Name:TEQUILA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:763-348-2075
Mailing Address - Fax:
Practice Address - Street 1:3710 LANDMARK DR STE 408
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4034
Practice Address - Country:US
Practice Address - Phone:803-227-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-24
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29092363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNN0622Medicaid