Healthcare Provider Details

I. General information

NPI: 1780687350
Provider Name (Legal Business Name): GARY T. ANDERSON F.N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 LUNDORFF DR
SANDSTONE MN
55072-5051
US

IV. Provider business mailing address

204 LUNDORFF DR
SANDSTONE MN
55072-5051
US

V. Phone/Fax

Practice location:
  • Phone: 320-245-2250
  • Fax: 320-245-2555
Mailing address:
  • Phone: 320-245-2250
  • Fax: 320-245-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR 120278-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: