Basic Information
| Provider Information | |||||||||
| NPI: | 1932644903 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAIBERGER | ||||||||
| FirstName: | ANDREA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 AUDEN AVE APT 313 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432151970 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 793 W STATE ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432221551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142345000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2016 | ||||||||
| LastUpdateDate: | 01/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APRN.CRNA.019534 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | ARNP9356865 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 003185986A | 05 | GA | MEDICAID | 019992600 | 05 | FL | MEDICAID |