Shirley M Anderson, MA CCCA – Audiologist

Key facts

NPI: 1124007463
Entity type: Individual (NPI type 1)
Primary specialty: Audiologist 231H00000X
License: 6054 (MN)
Practice address: 1421 Premier Dr
Mankato Clinic at Wickersham Campus
Mankato, MN 56001
Phone: (507) 625-1811
NPI assigned: Jan 14, 2006
Sex: Female
Sole proprietor: No

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): Yes
Credentials: Master of Arts

State licenses

License	State	Type	Specialty
6054	MN	MD	Audiologist

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Audiologist	231H00000X	6054	MN	Yes

Addresses

Primary practice location

1421 Premier Dr
Mankato Clinic at Wickersham Campus
Mankato, MN 56001

Mailing address

PO Box 8674
1230 E Main St
Mankato, MN 56002-8674
Phone (507) 625-1811

Other identifiers

Identifier	Type	State	Issuer
586515800	Medicaid	MN
NA2951023870	Other	MN	PREFERRED ONE
29Q96AN	Other	MN	BCBS
117664	Other	MN	UCARE
640003648	Other		RR MEDICARE
1758785	Other	MN	AMERICAS PPO
4511090	Other	MN	MEDICA
HP40597	Other	MN	HEALTH PARTNERS

Electronic endpoints

Type	Endpoint	Use	Affiliation
Direct Messaging Address	shirleyanderson@mklt.allscriptsdirect.net	Direct

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jul 9, 2020.

{
    "created_epoch": "1137196800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1594252800000",
    "number": "1124007463",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 8674",
            "address_2": "1230 E MAIN ST",
            "city": "MANKATO",
            "state": "MN",
            "postal_code": "560028674",
            "telephone_number": "507-625-1811"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1421 PREMIER DR",
            "address_2": "MANKATO CLINIC AT WICKERSHAM CAMPUS",
            "city": "MANKATO",
            "state": "MN",
            "postal_code": "56001",
            "telephone_number": "507-625-1811"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ANDERSON",
        "first_name": "SHIRLEY",
        "middle_name": "M",
        "credential": "MA CCCA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-01-14",
        "last_updated": "2020-07-09",
        "certification_date": "2020-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "231H00000X",
            "taxonomy_group": "",
            "desc": "Audiologist",
            "state": "MN",
            "license": "6054",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "586515800",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREFERRED ONE",
            "identifier": "NA2951023870",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "29Q96AN",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCARE",
            "identifier": "117664",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "640003648",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AMERICAS PPO",
            "identifier": "1758785",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA",
            "identifier": "4511090",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH PARTNERS",
            "identifier": "HP40597",
            "state": "MN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "shirleyanderson@mklt.allscriptsdirect.net",
            "affiliation": "N",
            "endpointDescription": "Mankato Clinic Direct ID, Allscripts Community",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "1421 Premier Dr",
            "address_2": "Mankato Clinic at Wickersham Campus",
            "city": "Mankato",
            "state": "MN",
            "country_code": "US",
            "postal_code": "56001",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Mankato, MN

All providers in Mankato, MN · Audiologist in Minnesota

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 9, 2020. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.