Provider Demographics
NPI:1487792131
Name:ANDERSON, KIPLEY VERNE (CRNA,BSN,MS,CH)
Entity type:Individual
Prefix:
First Name:KIPLEY
Middle Name:VERNE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CRNA,BSN,MS,CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 200TH ST
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-4501
Mailing Address - Country:US
Mailing Address - Phone:712-246-1774
Mailing Address - Fax:
Practice Address - Street 1:2959 HWY 275
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:IA
Practice Address - Zip Code:51640
Practice Address - Country:US
Practice Address - Phone:712-382-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078742163W00000X
IAD-078742367500000X
MO122072163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO913640942Medicaid
IA1487792131Medicaid