Provider Demographics
NPI:1790022697
Name:ANDERSON, JOHN THEODORE (ARNP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THEODORE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 ELM ST
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-5108
Mailing Address - Country:US
Mailing Address - Phone:307-324-2221
Mailing Address - Fax:
Practice Address - Street 1:104 E 3RD ST
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:IA
Practice Address - Zip Code:51463-5027
Practice Address - Country:US
Practice Address - Phone:712-669-3894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-108960363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner