Healthcare Provider Details

I. General information

NPI: 1609059567
Provider Name (Legal Business Name): MICHAEL JONAH RUBIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 12/03/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 S ROCK ST WESTLAKE ANESTHESIA GROUP, PA
GEORGETOWN TX
78626-5837
US

IV. Provider business mailing address

1004 S ROCK ST WESTLAKE ANESTHESIA GROUP, PA
GEORGETOWN TX
78626-5837
US

V. Phone/Fax

Practice location:
  • Phone: 512-279-0348
  • Fax: 512-371-8788
Mailing address:
  • Phone: 512-279-0348
  • Fax: 512-371-8788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22618
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number638205
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN 4265
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number078638
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP122874
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: