Basic Information
| Provider Information | |||||||||
| NPI: | 1194398867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 OLD STATE RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190641727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4129529991 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 ROSE ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405361727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235956 | ||||||||
| FaxNumber: | 8593231080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2021 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN667292 | PA | N | Nursing Service Providers | Registered Nurse | 367500000X | 3017184 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.