Provider Demographics
NPI:1801610969
Name:ANDERSON, IAN (HIS)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 MOUNTAIN SHADOW DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3838
Mailing Address - Country:US
Mailing Address - Phone:218-722-6611
Mailing Address - Fax:218-249-0736
Practice Address - Street 1:2216 MOUNTAIN SHADOW DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-3838
Practice Address - Country:US
Practice Address - Phone:218-722-6611
Practice Address - Fax:218-249-0736
Is Sole Proprietor?:No
Enumeration Date:2024-11-14
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2075-60237700000X
MN2965237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist