Provider Demographics
NPI:1407150071
Name:BANTA, ANDREA BAUER (CRN)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:BAUER
Last Name:BANTA
Suffix:
Gender:F
Credentials:CRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11120 SW 58TH CT
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5015
Mailing Address - Country:US
Mailing Address - Phone:305-794-9016
Mailing Address - Fax:
Practice Address - Street 1:1613 HARRISON PKWY
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2896
Practice Address - Country:US
Practice Address - Phone:180-043-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9222380163W00000X
FLARNP9222380367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse