Provider Demographics
NPI:1184183436
Name:RANDTKE, MARK ANDREW (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:RANDTKE
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 1:8717 W 110TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2126
Mailing Address - Country:US
Mailing Address - Phone:913-428-2900
Mailing Address - Fax:913-428-2951
Practice Address - Street 1:2100 SE BLUE PKWY
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-1007
Practice Address - Country:US
Practice Address - Phone:816-282-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020024635367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered