Provider Demographics
NPI:1265657001
Name:ANDERSEN, DAVID LYNN (RPT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LYNN
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:RPT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 TYRA DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4437
Mailing Address - Country:US
Mailing Address - Phone:208-681-2525
Mailing Address - Fax:
Practice Address - Street 1:363 TYRA DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4437
Practice Address - Country:US
Practice Address - Phone:208-681-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-322225100000X
IDAT-0042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0043961Medicaid
ID1650652Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER