Provider Demographics
NPI:1225174683
Name:ANDERSON, KIM ALAN (PT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ALAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2125
Mailing Address - Country:US
Mailing Address - Phone:612-707-0169
Mailing Address - Fax:612-465-1603
Practice Address - Street 1:2801 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2125
Practice Address - Country:US
Practice Address - Phone:612-707-0169
Practice Address - Fax:612-465-1603
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251E1200X, 2251S0007X, 2251X0800X
MN2787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic