Provider Demographics
NPI:1659634053
Name:ANDERSON, PETER ALAN (PT/DPT)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:ALAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT/DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 GOLD DR. S.
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6416
Mailing Address - Country:US
Mailing Address - Phone:701-451-9417
Mailing Address - Fax:701-298-0066
Practice Address - Street 1:1711 GOLD DR S
Practice Address - Street 2:SUITE 120
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6416
Practice Address - Country:US
Practice Address - Phone:701-451-9417
Practice Address - Fax:701-298-0066
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist