Basic Information
| Provider Information | |||||||||
| NPI: | 1306913934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 LILAC DR N STE 190 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632678701 | ||||||||
| FaxNumber: | 7062700487 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 LILAC DR N STE 190 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632678701 | ||||||||
| FaxNumber: | 7062700487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 13429 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.