Healthcare Provider Details

I. General information

NPI: 1538390257
Provider Name (Legal Business Name): ELIZABETH A ANDERSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N 1ST ST
STAYTON OR
97383-1704
US

IV. Provider business mailing address

314 APPLE ST
SILVERTON OR
97381-2002
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-3123
  • Fax:
Mailing address:
  • Phone: 503-551-0194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8609
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: