Basic Information
| Provider Information | |||||||||
| NPI: | 1003922790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 269 MORGAN'S ROAD | ||||||||
| Address2: | |||||||||
| City: | ANIAK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995570269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076754556 | ||||||||
| FaxNumber: | 9076754687 | ||||||||
| Practice Location | |||||||||
| Address1: | 269 MORGAN'S ROAD | ||||||||
| Address2: | |||||||||
| City: | ANIAK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995570269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076754556 | ||||||||
| FaxNumber: | 9076754687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 07/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 375970-1206 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1027 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MA1469368 | 01 | UT | DEA | OTHER |