Basic Information
| Provider Information | |||||||||
| NPI: | 1366705501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 843966 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641843966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738843300 | ||||||||
| FaxNumber: | 5738840943 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N KEENE ST STE 207 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652018104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737713970 | ||||||||
| FaxNumber: | 5732193964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2012 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 56472 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 2021009636 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | 56472 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | 2021009636 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 200095191 | 05 | MO | MEDICAID |