Healthcare Provider Details

I. General information

NPI: 1770143992
Provider Name (Legal Business Name): ALYCE ANDERSON MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-8383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number77975
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT218362
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number77975
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: