Provider Demographics
NPI:1649376179
Name:ANDERSON, ANDY MATTHEW (PA-A, AA-C)
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:MATTHEW
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA-A, AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 CRANE MILL RD
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:GA
Mailing Address - Zip Code:30510-3621
Mailing Address - Country:US
Mailing Address - Phone:706-968-4610
Mailing Address - Fax:
Practice Address - Street 1:1199 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2797
Practice Address - Country:US
Practice Address - Phone:706-475-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA726207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology