Basic Information
| Provider Information | |||||||||
| NPI: | 1649481698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | THOR | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 UNIVERSITY AVE W STE 110N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551142001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025309 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Practice Location | |||||||||
| Address1: | 6025 LAKE ROAD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517357414 | ||||||||
| FaxNumber: | 6517351827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 11/29/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 057335 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | R 228559-3 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.