Healthcare Provider Details

I. General information

NPI: 1689267890
Provider Name (Legal Business Name): JARED ROSS ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10561 JEFFREYS ST STE 230
HENDERSON NV
89052-4268
US

IV. Provider business mailing address

10561 JEFFREYS ST STE 230
HENDERSON NV
89052-4268
US

V. Phone/Fax

Practice location:
  • Phone: 702-819-8536
  • Fax: 702-948-1088
Mailing address:
  • Phone: 702-819-8536
  • Fax: 702-948-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2709
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: