Provider Demographics
NPI:1831371558
Name:ANDERSON, KIMBAL W (CRNA)
Entity type:Individual
Prefix:MR
First Name:KIMBAL
Middle Name:W
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 573369
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-3369
Mailing Address - Country:US
Mailing Address - Phone:818-884-7724
Mailing Address - Fax:818-884-7725
Practice Address - Street 1:PO BOX 573369
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91357-3369
Practice Address - Country:US
Practice Address - Phone:818-884-7724
Practice Address - Fax:818-884-7725
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP 60215085367500000X
OR200860001CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered