Healthcare Provider Details

I. General information

NPI: 1639149479
Provider Name (Legal Business Name): DR. CHARLES ABE ANDERSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

1302 28TH AVENUE CT
MILTON WA
98354-7007
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-3885
  • Fax: 253-968-5997
Mailing address:
  • Phone: 253-952-2135
  • Fax: 253-952-8816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number151353-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: