Provider Demographics
NPI:1073594966
Name:ANDERSON, SHELLY L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:5502 W BROADWAY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3508
Mailing Address - Country:US
Mailing Address - Phone:763-287-6500
Mailing Address - Fax:763-287-6544
Practice Address - Street 1:1495 HWY 101 NORTH
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447
Practice Address - Country:US
Practice Address - Phone:763-476-6776
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNE49047Medicare UPIN