Provider Demographics
NPI:1457302622
Name:HETLAND, ANDREW R (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:HETLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 TYLER PKWY STE 6
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0871
Mailing Address - Country:US
Mailing Address - Phone:701-258-6851
Mailing Address - Fax:
Practice Address - Street 1:2331 TYLER PKWY STE 6
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0871
Practice Address - Country:US
Practice Address - Phone:701-258-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1696207Y00000X
ND11581207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND715264Medicare PIN