Healthcare Provider Details

I. General information

NPI: 1023558434
Provider Name (Legal Business Name): DEREK ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 E HILLCOURT
WILLISTON ND
58801-4454
US

IV. Provider business mailing address

1227 E HILLCOURT
WILLISTON ND
58801-4454
US

V. Phone/Fax

Practice location:
  • Phone: 701-770-8141
  • Fax:
Mailing address:
  • Phone: 701-770-8141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: