Healthcare Provider Details

I. General information

NPI: 1558446997
Provider Name (Legal Business Name): PAUL YEBOAH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 INTERSTATE 30
MESQUITE TN
75150
US

IV. Provider business mailing address

6233 LOVE DRIVE APT 232
IRVING TN
75039
US

V. Phone/Fax

Practice location:
  • Phone: 972-681-7246
  • Fax: 972-681-8946
Mailing address:
  • Phone: 972-681-7246
  • Fax: 972-681-8946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number722797
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: