Basic Information
| Provider Information | |||||||||
| NPI: | 1750366480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530054266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627874026 | ||||||||
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| Practice Location | |||||||||
| Address1: | 112 E 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | ANTIGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544092710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156232331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 049068 | 01 | CRNA RECERTIFICATION CARD | OTHER | 43378100 | 05 | WI | MEDICAID |