1336430107 NPI number — DR. PATRICE LYNN ANDERSON M.D.

Table of content: DR. PATRICE LYNN ANDERSON M.D. (NPI 1336430107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336430107 NPI number — DR. PATRICE LYNN ANDERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
PATRICE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336430107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 BRADHURST AVE
Provider Second Line Business Mailing Address:
SUITE 3100N
Provider Business Mailing Address City Name:
HAWTHORNE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10532-2140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-909-9018
Provider Business Mailing Address Fax Number:
914-909-9028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 WOODS RD
Provider Second Line Business Practice Location Address:
N/A
Provider Business Practice Location Address City Name:
VALHALLA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10595-1530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-909-9018
Provider Business Practice Location Address Fax Number:
914-909-9028
Provider Enumeration Date:
04/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0127X , with the licence number:  MD452935 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 287946 . This is a "NYS LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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