Provider Demographics
NPI:1902202690
Name:SANDERS, TREVOR ERVIN (CRNA)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:ERVIN
Last Name:SANDERS
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 1:825 2ND AVE
Mailing Address - Street 2:SUITE C6
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1786
Mailing Address - Country:US
Mailing Address - Phone:270-393-1912
Mailing Address - Fax:270-393-1913
Practice Address - Street 1:250 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1760
Practice Address - Country:US
Practice Address - Phone:270-393-1912
Practice Address - Fax:270-393-1913
Is Sole Proprietor?:No
Enumeration Date:2014-11-07
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009119367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100330730Medicaid
KY7100330730Medicaid