Basic Information
| Provider Information | |||||||||
| NPI: | 1669041307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANDEFER | ||||||||
| FirstName: | ZACHARY | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5516 MORO RD | ||||||||
| Address2: | |||||||||
| City: | MORO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620671310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185310517 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184637311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2021 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209023397 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.