Provider Demographics
NPI:1891266524
Name:ANDERSON, MATTHEW (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:50 HIDDEN VIEW LN
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-1378
Mailing Address - Country:US
Mailing Address - Phone:304-312-5586
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-1200
Practice Address - Country:US
Practice Address - Phone:304-312-5586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV78163163WF0300X
WV124997367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WF0300XNursing Service ProvidersRegistered NurseFlight