Provider Demographics
NPI:1992995088
Name:BALDWIN, ANDREA L (CRNA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1235 E CHEROKEE ST
Mailing Address - Street 2:ANESTHESIA
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2203
Mailing Address - Country:US
Mailing Address - Phone:417-820-6863
Mailing Address - Fax:417-820-6868
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:ANESTHESIA
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-6863
Practice Address - Fax:417-820-6868
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003012794367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00709665OtherRAILROAD MEDICARE
AR176948001Medicaid
431560263OtherTRICARE WEST
MO1992995088Medicaid
431560263OtherTRICARE WEST