Healthcare Provider Details

I. General information

NPI: 1902661085
Provider Name (Legal Business Name): EGON LYTTLE JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 RED RIVER ST
AUSTIN TX
78701-1918
US

IV. Provider business mailing address

2716 BAGBY ST
HOUSTON TX
77006-2204
US

V. Phone/Fax

Practice location:
  • Phone: 512-689-4089
  • Fax:
Mailing address:
  • Phone: 832-366-4263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number147248
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: