Provider Demographics
NPI:1710026422
Name:ANDERSON, KENNETH STEPHEN (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:STEPHEN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:K
Other - Middle Name:STEPHEN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:1442 BIEBEL AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2846
Mailing Address - Country:US
Mailing Address - Phone:814-864-7775
Mailing Address - Fax:814-877-6070
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-2080
Practice Address - Fax:814-877-6070
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN187319L372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider