Provider Demographics
NPI:1659310829
Name:ANDERSON, KERRY W (DPM)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 N LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8703
Mailing Address - Country:US
Mailing Address - Phone:208-327-0627
Mailing Address - Fax:208-376-5258
Practice Address - Street 1:809 N LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8703
Practice Address - Country:US
Practice Address - Phone:208-327-0627
Practice Address - Fax:208-376-5258
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP144213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004395700Medicaid
ID1350764Medicare ID - Type Unspecified