Healthcare Provider Details

I. General information

NPI: 1386984615
Provider Name (Legal Business Name): ANDREW LEE GOODEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2013
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

ONE CHILDREN'S PLAZA DAYTON CHILDREN'S HOSPITAL-CHILDREN'S ANESTHESIA GROUP,
DAYTON OH
45404-1815
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-2727
  • Fax:
Mailing address:
  • Phone: 937-641-3350
  • Fax: 937-641-6145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2019003627
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA.14539NA
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN.391120-1
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: