Healthcare Provider Details

I. General information

NPI: 1720064918
Provider Name (Legal Business Name): GARY S. ANDERSON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 LOUGHBORO RD NW
WASHINGTON DC
20016-2695
US

IV. Provider business mailing address

PO BOX 65266
CHARLOTTE NC
28265-0266
US

V. Phone/Fax

Practice location:
  • Phone: 202-537-4080
  • Fax: 202-537-4588
Mailing address:
  • Phone: 800-377-8721
  • Fax: 304-523-2241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA216
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: