Provider Demographics
NPI:1144337916
Name:ANDERSON, PETER WILLIAM (DC, PA-C)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:WILLIAM
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 NE EVANS ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-3925
Mailing Address - Country:US
Mailing Address - Phone:503-434-9002
Mailing Address - Fax:
Practice Address - Street 1:3025 RYAN DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5057
Practice Address - Country:US
Practice Address - Phone:503-540-9999
Practice Address - Fax:503-540-3105
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR197354363AM0700X
OR2958111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGHJCMedicare ID - Type Unspecified