Provider Demographics
NPI:1164701041
Name:BENGTSON, ANDERS PAUL (PA)
Entity Type:Individual
Prefix:
First Name:ANDERS
Middle Name:PAUL
Last Name:BENGTSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:153 CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:W. ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2226
Mailing Address - Country:US
Mailing Address - Phone:651-222-1816
Mailing Address - Fax:651-222-1305
Practice Address - Street 1:153 CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:W. ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2226
Practice Address - Country:US
Practice Address - Phone:651-222-1816
Practice Address - Fax:651-222-1305
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1608363A00000X
MN10962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant