Healthcare Provider Details

I. General information

NPI: 1447423603
Provider Name (Legal Business Name): ANTHONY WYATT ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SMITH AVE N STE 300
SAINT PAUL MN
55102
US

IV. Provider business mailing address

225 SMITH AVE N STE 300
SAINT PAUL MN
55102-2592
US

V. Phone/Fax

Practice location:
  • Phone: 651-952-9777
  • Fax:
Mailing address:
  • Phone: 651-952-9777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number60649
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number60649
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: