Healthcare Provider Details

I. General information

NPI: 1184183436
Provider Name (Legal Business Name): MARK ANDREW RANDTKE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2019
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SE BLUE PKWY
LEES SUMMIT MO
64063-1007
US

IV. Provider business mailing address

8717 W 110TH ST STE 600
OVERLAND PARK KS
66210-2126
US

V. Phone/Fax

Practice location:
  • Phone: 816-282-5000
  • Fax:
Mailing address:
  • Phone: 913-428-2900
  • Fax: 913-428-2951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2020024635
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: