1649481698 NPI number — BRUCE THOR ANDERSON CNP

Table of content: BRUCE THOR ANDERSON CNP (NPI 1649481698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649481698 NPI number — BRUCE THOR ANDERSON CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
BRUCE
Provider Middle Name:
THOR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649481698
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 UNIVERSITY AVE W STE 110N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-602-5309
Provider Business Mailing Address Fax Number:
651-222-6786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6025 LAKE ROAD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-1709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-735-7414
Provider Business Practice Location Address Fax Number:
651-735-1827
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  057335 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: R 228559-3 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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