Provider Demographics
NPI:1073657714
Name:ANDERSON, JOSHUA JASON (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:JASON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 E LAKE ST
Mailing Address - Street 2:SUITE#201
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1750
Mailing Address - Country:US
Mailing Address - Phone:612-242-2169
Mailing Address - Fax:612-724-9894
Practice Address - Street 1:1518 E LAKE ST
Practice Address - Street 2:SUITE#201
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1750
Practice Address - Country:US
Practice Address - Phone:612-242-2169
Practice Address - Fax:612-724-9894
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4060111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNVO8833Medicare UPIN