Healthcare Provider Details

I. General information

NPI: 1245861160
Provider Name (Legal Business Name): LANDON COLLIER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 8TH AVE
FORT WORTH TX
76104-4110
US

IV. Provider business mailing address

6225 N STATE HIGHWAY 161 STE 200
IRVING TX
75038-2241
US

V. Phone/Fax

Practice location:
  • Phone: 817-926-2544
  • Fax:
Mailing address:
  • Phone: 214-687-0001
  • Fax: 972-518-2100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9375164
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1000566
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: