Basic Information
| Provider Information | |||||||||
| NPI: | 1639149479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSEN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ABE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1302 28TH AVENUE CT | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983547007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539522135 | ||||||||
| FaxNumber: | 2539528816 | ||||||||
| Practice Location | |||||||||
| Address1: | 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539683885 | ||||||||
| FaxNumber: | 2539685997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 151353-1205 | UT | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.