Healthcare Provider Details

I. General information

NPI: 1386286276
Provider Name (Legal Business Name): JUSTIN EARL ANDERSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 12TH ST S
FARGO ND
58104-4034
US

IV. Provider business mailing address

642 12TH AVE E
WEST FARGO ND
58078-3119
US

V. Phone/Fax

Practice location:
  • Phone: 701-346-0222
  • Fax: 701-346-0223
Mailing address:
  • Phone: 218-242-2845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2388
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: