Provider Demographics
NPI:1174955306
Name:ANDERSEN, BRYCE WADE (NP-C)
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:WADE
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 N 700 E
Mailing Address - Street 2:
Mailing Address - City:FIRTH
Mailing Address - State:ID
Mailing Address - Zip Code:83236-1134
Mailing Address - Country:US
Mailing Address - Phone:208-521-3870
Mailing Address - Fax:
Practice Address - Street 1:3385 POTOMAC WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4978
Practice Address - Country:US
Practice Address - Phone:208-522-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP1303A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care