1346284320 NPI number — DEBRA MAE ANDERSON M.D.

Table of content: DEBRA MAE ANDERSON M.D. (NPI 1346284320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346284320 NPI number — DEBRA MAE ANDERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
DEBRA
Provider Middle Name:
MAE
Provider Name Prefix Text:
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:
1346284320
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2710 E HARNEY ST SUITE 100
Provider Second Line Business Mailing Address:
LARAMIE PHYSICIANS FOR CHILDREN
Provider Business Mailing Address City Name:
LARAMIE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82072-2884
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-721-3118
Provider Business Mailing Address Fax Number:
307-721-4880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2710 E HARNEY ST SUITE 100
Provider Second Line Business Practice Location Address:
LARAMIE PHYSICIANS FOR CHILDREN
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82072-2884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-721-3118
Provider Business Practice Location Address Fax Number:
307-721-4880
Provider Enumeration Date:
06/16/2006

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: 208000000X , with the licence number:  5481A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110108100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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