Provider Demographics
NPI:1447769997
Name:ANDERSON, IAN RADFORD (DPT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:RADFORD
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 1:2038 LAKE TAHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6499
Mailing Address - Country:US
Mailing Address - Phone:530-208-9910
Mailing Address - Fax:530-285-2001
Practice Address - Street 1:2038 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6499
Practice Address - Country:US
Practice Address - Phone:530-208-9910
Practice Address - Fax:530-285-2001
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8708225100000X
CA295037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist