Provider Demographics
NPI:1730779729
Name:ANDERSON, THEODORE MANN (PA-C)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:MANN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:225 HASTINGS ST NE APT 211
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1526
Mailing Address - Country:US
Mailing Address - Phone:616-821-4722
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:866-989-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant