Basic Information
| Provider Information | |||||||||
| NPI: | 1649303165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | P.A.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E CHURCH STREET | ||||||||
| Address2: | MEDICAL STAFF | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934542537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393114 | ||||||||
| FaxNumber: | 8057393502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 ELLA ST STE A | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055499555 | ||||||||
| FaxNumber: | 8055490444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 15684 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA15684 | 01 | CA | PHYSICIAN ASSISTANT LICENSE | OTHER | MA2293455 | 01 | CA | DEA | OTHER |