Provider Demographics
NPI:1386078715
Name:ANDERSON, NATHAN WALLACE (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:WALLACE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 E HWY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9596
Mailing Address - Fax:
Practice Address - Street 1:622 W STATE HWY 71
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602
Practice Address - Country:US
Practice Address - Phone:512-483-9596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60866922207Q00000X, 207Q00000X
TXT1634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX427582801Medicaid
TX427582802Medicaid