Provider Demographics
NPI:1083691448
Name:ANDERSON, GREGORY J (CRNA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 3RD ST SE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3557
Mailing Address - Country:US
Mailing Address - Phone:320-632-5743
Mailing Address - Fax:320-632-9680
Practice Address - Street 1:808 3RD ST SE
Practice Address - Street 2:SUITE 130
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3557
Practice Address - Country:US
Practice Address - Phone:320-632-5743
Practice Address - Fax:320-632-9680
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1442120367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44344900Medicaid