1457994584 NPI number — PAMELA J ANDERSEN MT-BC, NMT MEMBER

Table of content: CAROLINE SYMONS PA-C (NPI 1780303180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457994584 NPI number — PAMELA J ANDERSEN MT-BC, NMT MEMBER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSEN
Provider First Name:
PAMELA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MT-BC, NMT MEMBER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EMRICH
Provider Other First Name:
PAMELA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RMT-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457994584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 N. METRO DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-903-1009
Provider Business Mailing Address Fax Number:
800-791-3601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 N. METRO DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLETON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-903-1009
Provider Business Practice Location Address Fax Number:
800-791-3601
Provider Enumeration Date:
10/22/2019

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: 225A00000X , with the licence number:  13260 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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