Provider Demographics
NPI:1538239850
Name:JACK-MURDOCK, ANDREA MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:JACK-MURDOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2897
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-2897
Mailing Address - Country:US
Mailing Address - Phone:800-374-5326
Mailing Address - Fax:800-374-7656
Practice Address - Street 1:224 E DOUGLAS AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3423
Practice Address - Country:US
Practice Address - Phone:316-264-1757
Practice Address - Fax:316-264-1907
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55536367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS145392OtherBCBS OF KS
KS200419150AMedicaid
P00398985OtherRR MEDICARE GROUP CQ2302