Provider Demographics
NPI:1225536592
Name:ANDERSON, BRANDON MARK (RN, CNP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:MARK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 SAINT JOHN DR
Mailing Address - Street 2:
Mailing Address - City:ORR
Mailing Address - State:MN
Mailing Address - Zip Code:55771-8232
Mailing Address - Country:US
Mailing Address - Phone:218-757-3650
Mailing Address - Fax:
Practice Address - Street 1:5219 SAINT JOHN DR
Practice Address - Street 2:
Practice Address - City:ORR
Practice Address - State:MN
Practice Address - Zip Code:55771-8232
Practice Address - Country:US
Practice Address - Phone:218-757-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN227183-7163W00000X
MNXXX363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse