Healthcare Provider Details

I. General information

NPI: 1093092926
Provider Name (Legal Business Name): MARY RUTH ANDERSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2011
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6826 PLUM CREEK DR
AMARILLO TX
79124-1601
US

IV. Provider business mailing address

3419 22ND ST
LUBBOCK TX
79410-1334
US

V. Phone/Fax

Practice location:
  • Phone: 806-322-3000
  • Fax: 806-322-3006
Mailing address:
  • Phone: 806-796-3000
  • Fax: 806-796-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number733590
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP120985
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: