Healthcare Provider Details

I. General information

NPI: 1922108992
Provider Name (Legal Business Name): ANTHONY D ANDERSON LMP,PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

IV. Provider business mailing address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

V. Phone/Fax

Practice location:
  • Phone: 971-206-5166
  • Fax: 971-206-5211
Mailing address:
  • Phone: 971-206-5166
  • Fax: 971-206-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00019881
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: