Provider Demographics
NPI:1750744942
Name:ANDERSON, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
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 262
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0262
Mailing Address - Country:US
Mailing Address - Phone:406-676-5680
Mailing Address - Fax:
Practice Address - Street 1:63351 US HIGHWAY 93
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-2702
Practice Address - Country:US
Practice Address - Phone:406-676-5680
Practice Address - Fax:406-676-5690
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT390200000X
MTMED-PHYS-LIC-99858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program