Healthcare Provider Details

I. General information

NPI: 1598389306
Provider Name (Legal Business Name): ANDREW RICHARDSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 BOWLES AVE
FENTON MO
63026-2394
US

IV. Provider business mailing address

400 S WOODS MILL RD STE 140
CHESTERFIELD MO
63017-3427
US

V. Phone/Fax

Practice location:
  • Phone: 636-496-2000
  • Fax:
Mailing address:
  • Phone: 314-485-1101
  • Fax: 314-485-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2020015034
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: