Basic Information
| Provider Information | |||||||||
| NPI: | 1558577189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANDERMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 247 MARCELLUS DR | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404032008 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2301 HOLMES ST | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641082640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164041127 | ||||||||
| FaxNumber: | 8164041103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 134568 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 134568 | 01 | MO | MO RN LICENSE | OTHER | 1477923102 | 01 | KS | KS RN LICENSE | OTHER |