Basic Information
| Provider Information | |||||||||
| NPI: | 1093782542 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERS | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | R PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2003 | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154463904 | ||||||||
| FaxNumber: | 3154452936 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 W GENESEE ST | ||||||||
| Address2: | SUITE 132 | ||||||||
| City: | CAMILLUS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130313200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154875858 | ||||||||
| FaxNumber: | 3154871950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 010011 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.