Provider Demographics
NPI:1568439131
Name:ANDERSON, STEPHANIE LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEIGH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7600 FRANCE AVE S STE 4100
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5924
Mailing Address - Country:US
Mailing Address - Phone:952-831-1551
Mailing Address - Fax:952-831-0725
Practice Address - Street 1:7600 FRANCE AVE S STE 4100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5924
Practice Address - Country:US
Practice Address - Phone:952-831-1551
Practice Address - Fax:952-831-0725
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN629712900Medicaid
MN080014299Medicare PIN
MN629712900Medicaid