Provider Demographics
NPI:1629177407
Name:ANDERSEN, KEITH C (CRNA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:C
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8681 EAGLE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8628
Mailing Address - Country:US
Mailing Address - Phone:651-251-0821
Mailing Address - Fax:651-251-8050
Practice Address - Street 1:69 EXCHANGE ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1004
Practice Address - Country:US
Practice Address - Phone:651-735-0501
Practice Address - Fax:651-735-1870
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1107740367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN593516400Medicaid
MN593516400Medicaid