Provider Demographics
NPI:1780613042
Name:ANDERSON, PAUL RAYMOND (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:RAYMOND
Last Name:ANDERSON
Suffix:
Gender:
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:218-683-2725
Mailing Address - Fax:
Practice Address - Street 1:1750 47TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7595
Practice Address - Country:US
Practice Address - Phone:701-757-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0289363A00000X
MN9547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1780613042Medicare PIN
970001656Medicare ID - Type Unspecified
P12590Medicare UPIN