Healthcare Provider Details

I. General information

NPI: 1639405947
Provider Name (Legal Business Name): JOHN NELS ANDERSON MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 N BINKLEY ST
SOLDOTNA AK
99669-7523
US

IV. Provider business mailing address

265 N BINKLEY ST
SOLDOTNA AK
99669-7523
US

V. Phone/Fax

Practice location:
  • Phone: 907-262-4161
  • Fax: 907-262-1545
Mailing address:
  • Phone: 907-262-4161
  • Fax: 907-262-1545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1677
License Number StateAK

VIII. Authorized Official

Name: JOHN NELS ANDERSON
Title or Position: SOLE PROPRIETOR
Credential: M.D.
Phone: 907-262-4161