Provider Demographics
NPI:1265870117
Name:ANDERSON, DAVID DWYNN (PT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:DWYNN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 S MILLENIUM WAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6439
Mailing Address - Country:US
Mailing Address - Phone:208-884-4647
Mailing Address - Fax:208-884-8984
Practice Address - Street 1:1618 S MILLENIUM WAY
Practice Address - Street 2:SUITE 210
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6439
Practice Address - Country:US
Practice Address - Phone:208-884-4647
Practice Address - Fax:208-884-8984
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist