Healthcare Provider Details

I. General information

NPI: 1538962121
Provider Name (Legal Business Name): STEPHANIE ANDERSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 WENTWORTH AVE E
WEST SAINT PAUL MN
55118-3525
US

IV. Provider business mailing address

2025 SLOAN PL STE 35
SAINT PAUL MN
55117-2092
US

V. Phone/Fax

Practice location:
  • Phone: 651-788-4444
  • Fax: 651-455-3354
Mailing address:
  • Phone: 651-772-1572
  • Fax: 651-772-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15468
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: