Provider Demographics
NPI:1659318863
Name:ANDERSON, CHARLES R JR (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:ANDERSON
Suffix:JR
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 1:2938 ROLLING BROAK DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-7469
Mailing Address - Country:US
Mailing Address - Phone:407-857-3161
Mailing Address - Fax:
Practice Address - Street 1:700 W OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4924
Practice Address - Country:US
Practice Address - Phone:407-846-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2776592367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
430077443OtherMEDICARE RAILROAD
FL304980900Medicaid
FLG1754OtherBLUE CROSS
430077443OtherMEDICARE RAILROAD