Provider Demographics
NPI:1972154649
Name:ANDERSON, DUANE GABRIEL JR
Entity type:Individual
Prefix:MR
First Name:DUANE
Middle Name:GABRIEL
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 PLUMAS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-1513
Mailing Address - Country:US
Mailing Address - Phone:619-254-6812
Mailing Address - Fax:
Practice Address - Street 1:3130 ORCHARD HILL RD
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1411
Practice Address - Country:US
Practice Address - Phone:479-461-4103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF7056292OtherDRIVER LICENSE