Provider Demographics
NPI:1164907408
Name:CARPENTER, JEFF ANDREW (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:ANDREW
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-5500
Mailing Address - Country:US
Mailing Address - Phone:806-220-9802
Mailing Address - Fax:
Practice Address - Street 1:1124 W 21ST ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-5500
Practice Address - Country:US
Practice Address - Phone:316-300-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSTMP-157280367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered