Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 66770 | MN |
NPI | 1003303439 |
---|---|
Provider Name | John Soontohrn Anderson |
First Address | Morris, MN 56267-1408 |
Second Address | Morris, MN 56267-1408 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2018 |
Last Update Date | 29/06/2021 |