Provider Demographics
NPI:1700310406
Name:ANDERSON, TIA (CRNA)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:
Other - Last Name:SHOMBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2401 GILLHAM RD
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-701-5200
Mailing Address - Fax:816-302-9939
Practice Address - Street 1:8717 W 110TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2144
Practice Address - Country:US
Practice Address - Phone:913-428-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43557509011367500000X
MO2010025473367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered