Provider Demographics
NPI:1053417840
Name:ANDERSON, WAYNE L (MD)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 15TH AVE W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801
Mailing Address - Country:US
Mailing Address - Phone:701-572-4003
Mailing Address - Fax:701-572-4007
Practice Address - Street 1:1213 15TH AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801
Practice Address - Country:US
Practice Address - Phone:701-572-4003
Practice Address - Fax:701-572-4007
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4768208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20537OtherBLUE CROSS
MT0040157Medicaid
ND17987Medicaid
NDN20537Medicare ID - Type Unspecified
MT0040157Medicaid