1689667727 NPI number — DIANE D AVERY CRNA

Table of content: DIANE D AVERY CRNA (NPI 1689667727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689667727 NPI number — DIANE D AVERY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AVERY
Provider First Name:
DIANE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PORTWOOD
Provider Other First Name:
DIANE
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689667727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3899
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79923-3899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-577-0030
Provider Business Mailing Address Fax Number:
915-533-2568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2415 E YANDELL DR
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79903-3616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-577-0030
Provider Business Practice Location Address Fax Number:
915-533-2568
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  426206 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22625 . This is a "NURSE ANESTHETISTS" identifier . This identifiers is of the category "OTHER".




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