Provider Demographics
NPI:1851025894
Name:ANDERSON, RILEY EVAN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:EVAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 GRAND AVE APT 30
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4127
Mailing Address - Country:US
Mailing Address - Phone:712-330-4829
Mailing Address - Fax:
Practice Address - Street 1:6500 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-5357
Practice Address - Country:US
Practice Address - Phone:712-330-4829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1090702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer