Provider Demographics
NPI:1194702233
Name:ANDERSON, PHILIP J (PT)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12239 MADRONA WAY
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959
Mailing Address - Country:US
Mailing Address - Phone:530-477-0868
Mailing Address - Fax:
Practice Address - Street 1:202 PROVIDENCE MINE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-2947
Practice Address - Country:US
Practice Address - Phone:530-477-0868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 10490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PT104902Medicare PIN