Healthcare Provider Details

I. General information

NPI: 1487753364
Provider Name (Legal Business Name): DURAND WAGNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13601 PRESTON RD STE 1000W
DALLAS TX
75240-4911
US

IV. Provider business mailing address

PO BOX 650426
DALLAS TX
75265-0426
US

V. Phone/Fax

Practice location:
  • Phone: 972-715-5007
  • Fax: 972-715-5682
Mailing address:
  • Phone: 972-715-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1203497
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN0000039771
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN0000039771
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: