Healthcare Provider Details

I. General information

NPI: 1548366461
Provider Name (Legal Business Name): LAURIE ANDERSON PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 1/2 PROSPECT BLVD
PASADENA CA
91103-3206
US

IV. Provider business mailing address

800 1/2 PROSPECT BLVD
PASADENA CA
91103-3206
US

V. Phone/Fax

Practice location:
  • Phone: 626-441-6098
  • Fax:
Mailing address:
  • Phone: 626-441-6098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberPA13069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: