Provider Demographics
NPI:1548366461
Name:ANDERSON, LAURIE (PAC)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 1/2 PROSPECT BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3206
Mailing Address - Country:US
Mailing Address - Phone:626-441-6098
Mailing Address - Fax:
Practice Address - Street 1:800 1/2 PROSPECT BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-3206
Practice Address - Country:US
Practice Address - Phone:626-441-6098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13069207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13069Medicaid
P04189Medicare UPIN
CAWPA13069AMedicare ID - Type Unspecified