Healthcare Provider Details

I. General information

NPI: 1316990666
Provider Name (Legal Business Name): CHARLES CHRISTIAN ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 8TH AVE SUITE 4300
SPOKANE WA
99204-2307
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-747-6707
  • Fax:
Mailing address:
  • Phone: 509-747-6707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberMD00041066
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberM-8783
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD00041066
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: