Provider Demographics
NPI:1013080316
Name:ANDERSON, MARY KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 OSBORNE RD NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2773
Mailing Address - Country:US
Mailing Address - Phone:763-785-4500
Mailing Address - Fax:763-785-3329
Practice Address - Street 1:480 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2773
Practice Address - Country:US
Practice Address - Phone:763-785-4500
Practice Address - Fax:763-785-3329
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
625A6ANOtherBLUE CROSS OF MN
138758OtherUCARE
HP73373OtherHEALTHPARTNERS
MN816420000Medicaid
HP73373OtherHEALTHPARTNERS
Q74208Medicare UPIN