Basic Information
| Provider Information | |||||||||
| NPI: | 1184822777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AANONSEN | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 EDGEWATER ST | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103054900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182264324 | ||||||||
| FaxNumber: | 7182261039 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 SEAVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182269158 | ||||||||
| FaxNumber: | 7182266964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 02/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 012414 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02925648 | 05 | NY | MEDICAID |