Provider Demographics
NPI:1114036357
Name:ANDERSON, MARSHALL EARL JR (CRNA)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:EARL
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:UK HEALTHCARE DEPARTMENT OF ANESTHESIOLOGY
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-7001
Mailing Address - Country:US
Mailing Address - Phone:859-323-5956
Mailing Address - Fax:859-323-1080
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:UK HEALTHCARE DEPARTMENT OF ANESTHESIOLOGY
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-7001
Practice Address - Country:US
Practice Address - Phone:859-323-5956
Practice Address - Fax:859-323-1080
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12677367500000X
KY3004822367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74011412Medicaid
KY1228911Medicare PIN