Basic Information
| Provider Information | |||||||||
| NPI: | 1023057056 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2840 CROOKS RD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483093619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488529290 | ||||||||
| FaxNumber: | 2488520305 | ||||||||
| Practice Location | |||||||||
| Address1: | 2840 CROOKS RD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483093619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488529290 | ||||||||
| FaxNumber: | 2488520305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 08/31/2007 | ||||||||
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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 | 5601001421 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 5601001421 | 01 | MI | PA LICENSE | OTHER |