Healthcare Provider Details

I. General information

NPI: 1497933170
Provider Name (Legal Business Name): STACY MARIE ANDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6350 W 143RD ST STE 102
SAVAGE MN
55378-2890
US

IV. Provider business mailing address

6350 W 143RD ST STE 102
SAVAGE MN
55378-2890
US

V. Phone/Fax

Practice location:
  • Phone: 952-428-0200
  • Fax:
Mailing address:
  • Phone: 952-428-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: