Provider Demographics
NPI:1295989929
Name:WANDOLOWSKI, KEITH (CRNA)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WANDOLOWSKI
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 1:14161 BARONESS CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7801
Mailing Address - Country:US
Mailing Address - Phone:206-850-9151
Mailing Address - Fax:
Practice Address - Street 1:10000 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761
Practice Address - Country:US
Practice Address - Phone:206-850-9151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA268405367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001017201Medicare PIN