Provider Demographics
NPI:1295358810
Name:STANDEFER, ANDREW JAMES (CRNA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMES
Last Name:STANDEFER
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 1:1206 MORELAND CT
Mailing Address - Street 2:
Mailing Address - City:MORO
Mailing Address - State:IL
Mailing Address - Zip Code:62067-1559
Mailing Address - Country:US
Mailing Address - Phone:618-210-1594
Mailing Address - Fax:
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6722
Practice Address - Country:US
Practice Address - Phone:618-463-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.448411163W00000X
IL209.021339367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse