Healthcare Provider Details

I. General information

NPI: 1174154413
Provider Name (Legal Business Name): ERIC ANDERSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16000 JOHNSTON MEMORIAL DR
ABINGDON VA
24211-7664
US

IV. Provider business mailing address

10415 WALLACE ALLEY ST
KINGSPORT TN
37663-3936
US

V. Phone/Fax

Practice location:
  • Phone: 276-258-1000
  • Fax:
Mailing address:
  • Phone: 423-390-0451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024178761
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number30278
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: