Healthcare Provider Details

I. General information

NPI: 1699330365
Provider Name (Legal Business Name): CODY MICHAEL ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 ENGINEERING DR
MADISON WI
53706-1607
US

IV. Provider business mailing address

1331 SOUTH ST APT 8
MADISON WI
53715-1950
US

V. Phone/Fax

Practice location:
  • Phone: 715-456-6305
  • Fax:
Mailing address:
  • Phone: 715-456-6305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: