MEDICARE: MR. ALLEN J THIBODEAUX JR. CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	699595	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	85524U	OTHER	TX	BCBSTX

General Provider Information

NPI Number	:	1326020421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALLEN J THIBODEAUX JR. CRNA

Provider Business Mailing Address
First Line	:	7502 BRIECESCO
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78414-6164
Country	:	US
Telephone Number	:	361-455-5358
Fax Number	:

Provider Business Practice Location Address
First Line	:	2606 HOSPITAL BLVD
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78405-1804
Country	:	US
Telephone Number	:	361-455-5358
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	08/01/2011

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