Provider Demographics
NPI:1215140751
Name:ANDERSON, ROBERT M (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:ANDERSON
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 1:10240 PRINCIPE PL
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8830
Mailing Address - Country:US
Mailing Address - Phone:805-375-7900
Mailing Address - Fax:
Practice Address - Street 1:10240 PRINCIPE PL
Practice Address - Street 2:
Practice Address - City:SANTA ROSA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93012-8830
Practice Address - Country:US
Practice Address - Phone:805-375-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14749OtherSTATE LICENSE NUMBER