Healthcare Provider Details

I. General information

NPI: 1811986193
Provider Name (Legal Business Name): GERALD H FORD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 BUFFALO GAP RD SUITE 2250
ABILENE TX
79606-2723
US

IV. Provider business mailing address

PO BOX 5409
ABILENE TX
79608-5409
US

V. Phone/Fax

Practice location:
  • Phone: 325-793-5380
  • Fax: 325-793-5259
Mailing address:
  • Phone: 325-793-5380
  • Fax: 325-793-5259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number038581
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: