Provider Demographics
NPI:1023063161
Name:ANDERSON, JOHN G (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:ANDERSON
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:PO BOX 70128
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30007-0128
Mailing Address - Country:US
Mailing Address - Phone:770-578-1800
Mailing Address - Fax:770-578-6168
Practice Address - Street 1:4575 N SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-6445
Practice Address - Country:US
Practice Address - Phone:770-454-4286
Practice Address - Fax:770-454-4065
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN065882367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000550569LMedicaid
GA43ZCBVW11Medicare ID - Type Unspecified