Provider Demographics
NPI:1073825089
Name:ANDERSON, JUDY L (PA-C)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 CHAUTAUQUA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-3145
Mailing Address - Country:US
Mailing Address - Phone:701-845-6000
Mailing Address - Fax:
Practice Address - Street 1:520 CHAUTAUQUA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-3145
Practice Address - Country:US
Practice Address - Phone:701-845-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant