Healthcare Provider Details

I. General information

NPI: 1164966081
Provider Name (Legal Business Name): AUSTIN MICHAEL THOMAS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 S OAK AVE #4
PASADENA CA
91107-4009
US

IV. Provider business mailing address

45 S. OAK AVE #4
PASADENA CA
91107
US

V. Phone/Fax

Practice location:
  • Phone: 509-845-1023
  • Fax:
Mailing address:
  • Phone: 509-845-1023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP132662
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: