Provider Demographics
NPI:1629366802
Name:NDERITU, ANTHONY WANJOHI (CRNA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WANJOHI
Last Name:NDERITU
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 1:13629 W EVANS DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-8349
Mailing Address - Country:US
Mailing Address - Phone:417-396-0013
Mailing Address - Fax:602-262-8890
Practice Address - Street 1:1850 N CENTRAL AVE
Practice Address - Street 2:SUITE 1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4527
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004022872367500000X
AZCRNA1078367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ173584Medicare UPIN