Healthcare Provider Details

I. General information

NPI: 1962485573
Provider Name (Legal Business Name): CONNIE S. ANDERSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 EKASTOWN RD COLONIAL CLINIC
SARVER PA
16055-9724
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

V. Phone/Fax

Practice location:
  • Phone: 724-353-1508
  • Fax: 724-353-2040
Mailing address:
  • Phone: 603-650-7901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number290725
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22230
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: