Healthcare Provider Details

I. General information

NPI: 1659608578
Provider Name (Legal Business Name): JEFFREY G. ANDERSON M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2009
Last Update Date: 11/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 461 MEDICAL UNIT
FPO AP
96521-0050
US

IV. Provider business mailing address

MEDICAL UNIT PSC 461, BOX 50
FPO AP
96521-0050
US

V. Phone/Fax

Practice location:
  • Phone: 861085314447
  • Fax: 861085313888
Mailing address:
  • Phone: 801-542-9751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: