Healthcare Provider Details

I. General information

NPI: 1164362760
Provider Name (Legal Business Name): TONY ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 MARINER DR
SAN FRANCISCO CA
94130-1210
US

IV. Provider business mailing address

1202 MARINER DR
SAN FRANCISCO CA
94130-1210
US

V. Phone/Fax

Practice location:
  • Phone: 619-359-2966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: