1891778510 NPI number — MR. DONALD WAYNE ANDERSON JR. CRNA

Table of content: PATRICIA ALICEA (NPI 1366676538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891778510 NPI number — MR. DONALD WAYNE ANDERSON JR. CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
DONALD
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891778510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
809 TYLER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21403-2805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-610-3257
Provider Business Mailing Address Fax Number:
443-610-3257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 S GREENE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21201-1544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-328-6704
Provider Business Practice Location Address Fax Number:
410-328-4124
Provider Enumeration Date:
11/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R107354 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 107500400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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