Provider Demographics
NPI:1417909003
Name:ANDERSON, PAUL R III (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:R
Last Name:ANDERSON
Suffix:III
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:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65302-1547
Mailing Address - Country:US
Mailing Address - Phone:660-826-5960
Mailing Address - Fax:
Practice Address - Street 1:215 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2705
Practice Address - Country:US
Practice Address - Phone:601-249-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1072774367500000X
MS875933367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00107335Medicaid
TN3636224Medicare ID - Type Unspecified