Provider Demographics
NPI:1962453993
Name:ANDERSEN, STEVEN LYNN (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:LYNN
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16366 PRISTINE PINE CT
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-6278
Mailing Address - Country:US
Mailing Address - Phone:218-232-7928
Mailing Address - Fax:
Practice Address - Street 1:16366 PRISTINE PINE CT
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-6278
Practice Address - Country:US
Practice Address - Phone:218-232-7928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43122-020207Q00000X
MN40222207Q00000X
WY8206A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN106516500Medicaid
WI34109000Medicaid
MN106516500Medicaid