Provider Demographics
NPI:1245740083
Name:ANDERSON, WESLEY (DPT)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 S CAROL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1839
Mailing Address - Country:US
Mailing Address - Phone:701-772-2200
Mailing Address - Fax:701-772-2800
Practice Address - Street 1:701 DEMERS AVE STE B
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4506
Practice Address - Country:US
Practice Address - Phone:701-772-2200
Practice Address - Fax:701-772-2800
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNPT-10789225100000X
NDPT-2220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPT-10789OtherSTATE LICENSE
NDPT-2220OtherSTATE LICENSE