Provider Demographics
NPI:1023453289
Name:VANDIVER, CHRISTOPHER ERIC (CRNA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ERIC
Last Name:VANDIVER
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 840
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-0840
Mailing Address - Country:US
Mailing Address - Phone:573-302-1661
Mailing Address - Fax:573-302-1719
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-302-1661
Practice Address - Fax:573-302-1719
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9359099163W00000X
MO2013037716367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1023453289Medicaid
MO602460007Medicare PIN