Provider Demographics
NPI:1861538860
Name:ANDERSON, CHRISTIAN B (DO)
Entity type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:B
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 W SHINAVA DR
Mailing Address - Street 2:
Mailing Address - City:IVINS
Mailing Address - State:UT
Mailing Address - Zip Code:84738-6713
Mailing Address - Country:US
Mailing Address - Phone:307-413-3752
Mailing Address - Fax:
Practice Address - Street 1:272 EAST CENTER STREET SUITE 102
Practice Address - Street 2:
Practice Address - City:IVINS
Practice Address - State:UT
Practice Address - Zip Code:84738-6456
Practice Address - Country:US
Practice Address - Phone:307-413-3752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7168A207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY7168AOtherSTATE LISCENSE NUMBER
UT12134634-1204OtherSTATE LISCENSE NUMBER
WY20239Medicare ID - Type UnspecifiedGROUP NUMBER
WYH63246Medicare UPIN