Provider Demographics
NPI:1326383100
Name:ANDERSON, KYLE C (CRNA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:C
Last Name:ANDERSON
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 1:7 WORKS WAY
Mailing Address - Street 2:
Mailing Address - City:SOMERSWORTH
Mailing Address - State:NH
Mailing Address - Zip Code:03878-1639
Mailing Address - Country:US
Mailing Address - Phone:603-841-2314
Mailing Address - Fax:603-841-2305
Practice Address - Street 1:22 BRIDGE ST STE 9
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-4987
Practice Address - Country:US
Practice Address - Phone:603-415-0090
Practice Address - Fax:603-692-1817
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA767058367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHPENDINGMedicaid