Provider Demographics
NPI:1619188604
Name:ANDRE, JEFFREY A (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:ANDRE
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 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:15200 COMMUNITY RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3085
Practice Address - Country:US
Practice Address - Phone:228-575-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA093642367500000X
TX779617367500000X
MS901434367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211608907Medicaid
LA1011886Medicaid
TX8839UAOtherBLUE CROSS BLUE SHIELD
TX211608906Medicaid
LA1011886Medicaid
TX8839UAOtherBLUE CROSS BLUE SHIELD