Provider Demographics
NPI:1851698344
Name:ANDERSON, ELISHA D (NP-C)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-683-4134
Mailing Address - Fax:701-683-4094
Practice Address - Street 1:819 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4244
Practice Address - Country:US
Practice Address - Phone:701-683-4134
Practice Address - Fax:701-683-4094
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR30898363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND84045Medicaid
ND84045Medicaid