Provider Demographics
NPI:1619545985
Name:GUM, ANDREA LEAANNE (CRNA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEAANNE
Last Name:GUM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LEAANNE
Other - Last Name:LEWANDOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1251 N PINE CLIFF DR APT 117
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3420
Mailing Address - Country:US
Mailing Address - Phone:574-806-3190
Mailing Address - Fax:
Practice Address - Street 1:77 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1479
Practice Address - Country:US
Practice Address - Phone:574-806-3190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28211820A367500000X
AZCNRA257352367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered