Provider Demographics
NPI:1255307047
Name:ANDERSON, GREG
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 W ORCHARD DR
Mailing Address - Street 2:SUITE #4
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1766
Mailing Address - Country:US
Mailing Address - Phone:360-318-8800
Mailing Address - Fax:360-318-1085
Practice Address - Street 1:722 N STATE ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5334
Practice Address - Country:US
Practice Address - Phone:360-752-2865
Practice Address - Fax:360-647-8093
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60043267207Q00000X
WA390200000X207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine