Provider Demographics
NPI:1891778510
Name:ANDERSON, DONALD WAYNE JR (CRNA)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:WAYNE
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:809 TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-2805
Mailing Address - Country:US
Mailing Address - Phone:443-610-3257
Mailing Address - Fax:443-610-3257
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6704
Practice Address - Fax:410-328-4124
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR107354367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD107500400Medicaid
MDI420Medicare PIN
MD107500400Medicaid