Healthcare Provider Details

I. General information

NPI: 1013080316
Provider Name (Legal Business Name): MARY KATHLEEN ANDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 OSBORNE RD NE
FRIDLEY MN
55432-2773
US

IV. Provider business mailing address

480 OSBORNE RD NE
FRIDLEY MN
55432-2773
US

V. Phone/Fax

Practice location:
  • Phone: 763-785-4500
  • Fax: 763-785-3329
Mailing address:
  • Phone: 763-785-4500
  • Fax: 763-785-3329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10146
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: