Provider Demographics
NPI:1386286276
Name:ANDERSON, JUSTIN EARL (DPT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:EARL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 12TH AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-3119
Mailing Address - Country:US
Mailing Address - Phone:218-242-2845
Mailing Address - Fax:
Practice Address - Street 1:5300 12TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4034
Practice Address - Country:US
Practice Address - Phone:701-346-0222
Practice Address - Fax:701-346-0223
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist