Basic Information
| Provider Information | |||||||||
| NPI: | 1487934865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | DREW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | J. | ||||||||
| OtherMiddleName: | DREW | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.A.-C. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 2000 1638 OWEN DRIVE | ||||||||
| Address2: | CAPE FEAR VALLEY MEDICAL CENTER EMERGENCY DEPARTMENT | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283142000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106158000 | ||||||||
| FaxNumber: | 9103216250 | ||||||||
| Practice Location | |||||||||
| Address1: | 1638 OWEN DRIVE | ||||||||
| Address2: | CAPE FEAR VALLEY MEDICAL CENTER EMERGENCY DEPARTMENT | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283142000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106158000 | ||||||||
| FaxNumber: | 9103216250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2011 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | C5-0000768 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | MA054881 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 0010-04177 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.