Provider Demographics
NPI:1356976724
Name:ADDLEY, ANDREW J (CRNA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:ADDLEY
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 GREENLEY RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5200
Mailing Address - Country:US
Mailing Address - Phone:209-770-4501
Mailing Address - Fax:
Practice Address - Street 1:1000 GREENLEY RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5200
Practice Address - Country:US
Practice Address - Phone:209-770-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95213005163WC0200X
ID67503367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine