Healthcare Provider Details

I. General information

NPI: 1003922790
Provider Name (Legal Business Name): CLINTON S ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 MORGAN'S ROAD
ANIAK AK
99557-0269
US

IV. Provider business mailing address

269 MORGAN'S ROAD
ANIAK AK
99557-0269
US

V. Phone/Fax

Practice location:
  • Phone: 907-675-4556
  • Fax: 907-675-4687
Mailing address:
  • Phone: 907-675-4556
  • Fax: 907-675-4687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number375970-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1027
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: