Provider Demographics
NPI:1114267960
Name:SANDERS, SUSYN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSYN
Middle Name:
Last Name:SANDERS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SUSYN
Other - Middle Name:M
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-1192
Mailing Address - Country:US
Mailing Address - Phone:660-885-5511
Mailing Address - Fax:
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2829
Practice Address - Fax:417-820-8852
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007003744367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1114267960Medicaid
MO132300333 OUTSIDEMedicare PIN
MO1114267960Medicaid