Healthcare Provider Details

I. General information

NPI: 1730545658
Provider Name (Legal Business Name): MR. ERASMO COUTINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

IV. Provider business mailing address

917 W BROADUS AVE
FORT WORTH TX
76115-2410
US

V. Phone/Fax

Practice location:
  • Phone: 817-319-0545
  • Fax:
Mailing address:
  • Phone: 817-319-0545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP129935
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number75563
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: