Provider Demographics
NPI:1053805887
Name:ANDERSON, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:CLAY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67432-1564
Mailing Address - Country:US
Mailing Address - Phone:785-632-2144
Mailing Address - Fax:
Practice Address - Street 1:609 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CLAY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67432-1564
Practice Address - Country:US
Practice Address - Phone:785-632-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-09622207Q00000X
KS04-43746207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine