Basic Information
| Provider Information | |||||||||
| NPI: | 1508852740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2142 N COVE BLVD | ||||||||
| Address2: | 5 NORTH PEDIATRICS | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192914637 | ||||||||
| FaxNumber: | 4194796012 | ||||||||
| Practice Location | |||||||||
| Address1: | 2142 N COVE BLVD | ||||||||
| Address2: | 5 NORTH PEDIATRICS | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192914637 | ||||||||
| FaxNumber: | 4194796012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 04/27/2012 | ||||||||
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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 | 50-001590 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00373668 | 01 | OH | RRMC | OTHER |