Provider Demographics
NPI:1538295977
Name:ANDERSON, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
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 1:10916 GREENBRIER RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-3474
Mailing Address - Country:US
Mailing Address - Phone:952-541-1799
Mailing Address - Fax:952-541-5451
Practice Address - Street 1:324 W WABASHA ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-1952
Practice Address - Country:US
Practice Address - Phone:218-722-6611
Practice Address - Fax:218-722-4235
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2623237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist