Basic Information
| Provider Information | |||||||||
| NPI: | 1770696999 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 BLAKESLEE ST | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146092209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852602222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 CORPORATE WOODS | ||||||||
| Address2: | C/O EVERCARE | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146231467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854633100 | ||||||||
| FaxNumber: | 5854633105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 06/02/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1363 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.