Provider Demographics
NPI:1962814616
Name:MEDEARIS, ANDREA MCCOY (CRNA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MCCOY
Last Name:MEDEARIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:L
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:
Practice Address - Street 1:3920 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4702
Practice Address - Country:US
Practice Address - Phone:502-259-6710
Practice Address - Fax:502-259-6704
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1123553367500000X
KY3008755367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300045950Medicaid
KY7100304640Medicaid