Provider Demographics
NPI:1336143940
Name:ANDERSEN, BRIAN ROBERT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:ROBERT
Last Name:ANDERSEN
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 1:2241 F. M. 984
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-0955
Mailing Address - Country:US
Mailing Address - Phone:972-646-5278
Mailing Address - Fax:972-646-5278
Practice Address - Street 1:3201 W HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2450
Practice Address - Country:US
Practice Address - Phone:903-654-6800
Practice Address - Fax:903-654-6989
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX705290367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1627689-02Medicaid