Basic Information
| Provider Information | |||||||||
| NPI: | 1720079981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | STACIA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 44297 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1030414 | 01 | PREFERRED ONE | OTHER | 1855107 | 01 | FIRST HEALTH PLAN | OTHER | 55G63AN | 01 | BLUE CROSS BLUE SHIELD | OTHER | COMP | 01 | MMSI | OTHER | 1545844 | 01 | ARAZ GROUP AMERICAS PPO | OTHER | C11369 | 01 | RR MEDICARE | OTHER | COMP | 01 | ONE HEALTH PLAN GREAT WES | OTHER | 0702359 | 01 | MEDICA HEALTH PLANS | OTHER | 160056138 | 01 | RR MEDICARE | OTHER | 052720300 | 01 | MEDICAL ASSISTANCE MA | OTHER | HP34883 | 01 | HEALTH PARTNERS | OTHER | COMP | 01 | CHAMPUS | OTHER | 141335 | 01 | U CARE | OTHER |