Provider Demographics
NPI:1326282898
Name:ANDERSON, BRANDON JOHN
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JOHN
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 1:4551 S 190TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-3683
Mailing Address - Country:US
Mailing Address - Phone:402-321-8725
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST. SE MMC 391
Practice Address - Street 2:PEDIATRIC EDUCATION EG
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-624-1192
Practice Address - Fax:612-626-7042
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program