Provider Demographics
NPI:1942748934
Name:ANDERSON, KADE (DPT)
Entity Type:Individual
Prefix:
First Name:KADE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 FALLS AVE E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3408
Mailing Address - Country:US
Mailing Address - Phone:208-736-2574
Mailing Address - Fax:208-736-2594
Practice Address - Street 1:1444 FALLS AVE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3408
Practice Address - Country:US
Practice Address - Phone:208-736-2574
Practice Address - Fax:208-736-2594
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-4936OtherID STATE LICENSE