Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | MD.06513R | LA |
NPI | 1255474466 |
---|---|
Provider Name | Miss Myra Louise Anderson |
First Address | Gonzales, LA 70737-8501 |
Second Address | Luling, LA 70070-4442 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B61532 | (02) | LA |