Basic Information
| Provider Information | |||||||||
| NPI: | 1750401998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANDT | ||||||||
| FirstName: | ANYA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANDECK | ||||||||
| OtherFirstName: | ANYA | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1310 COMMERCE STREET | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949541469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077787862 | ||||||||
| FaxNumber: | 7077780969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1660 SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949012707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152590131 | ||||||||
| FaxNumber: | 4152590133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 10/15/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | A65186 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | A65186 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207NS0135X | A65186 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
No ID Information.