Provider Demographics
NPI:1528182839
Name:ANDERSON, ANDREW E (PA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:E
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:PO BOX 1979
Mailing Address - Street 2:1340 N HWY 377 STE 110
Mailing Address - City:PILOT POINT
Mailing Address - State:TX
Mailing Address - Zip Code:76258-1979
Mailing Address - Country:US
Mailing Address - Phone:940-686-0860
Mailing Address - Fax:940-686-5834
Practice Address - Street 1:1340 N HIGHWAY 377 STE 110
Practice Address - Street 2:
Practice Address - City:PILOT POINT
Practice Address - State:TX
Practice Address - Zip Code:76258-3765
Practice Address - Country:US
Practice Address - Phone:940-686-0860
Practice Address - Fax:940-686-5834
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213110401Medicaid
TX8L26712Medicare PIN
OKL37016301Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC
OK1912944646Medicare UPIN
TX213110401Medicaid