Healthcare Provider Details

I. General information

NPI: 1780613042
Provider Name (Legal Business Name): PAUL RAYMOND ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 47TH AVE S
GRAND FORKS ND
58201-7595
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-757-8700
  • Fax:
Mailing address:
  • Phone: 218-683-2725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0289
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9547
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: