Healthcare Provider Details

I. General information

NPI: 1316107998
Provider Name (Legal Business Name): ANDREW MARK ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W 65TH ST
EDINA MN
55435-1706
US

IV. Provider business mailing address

4200 DAHLBERG DR SUITE 300
GOLDEN VALLEY MN
55422-4840
US

V. Phone/Fax

Practice location:
  • Phone: 952-456-7000
  • Fax: 952-456-7001
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10677
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: