Healthcare Provider Details

I. General information

NPI: 1336346360
Provider Name (Legal Business Name): ELIAS ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W JACKSON ST STE 206
CARBONDALE IL
62901-1474
US

IV. Provider business mailing address

PO BOX 1467
INDIANAPOLIS IN
46206-1467
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-3006
  • Fax: 618-457-3007
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002820
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: