1740288638 NPI number — DAVID F SELLERS CRNA

Table of content: DAVID F SELLERS CRNA (NPI 1740288638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740288638 NPI number — DAVID F SELLERS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELLERS
Provider First Name:
DAVID
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740288638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 988
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75504-0988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-793-7994
Provider Business Mailing Address Fax Number:
903-793-7996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4080 SUMMERHILL SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-2730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-793-7994
Provider Business Practice Location Address Fax Number:
903-793-7996
Provider Enumeration Date:
07/13/2005

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:  AP101349 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 235571 , 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: 84293C . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 97081 . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 109670303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 128073701 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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