Healthcare Provider Details

I. General information

NPI: 1760710149
Provider Name (Legal Business Name): THEODOOR CHRISTIAAN HANCKE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HIGHWAY 243 WEST
KAUFMAN TX
75142
US

IV. Provider business mailing address

PO BOX 650252
DALLAS TX
75265-0252
US

V. Phone/Fax

Practice location:
  • Phone: 972-932-7200
  • Fax: 817-861-3926
Mailing address:
  • Phone: 888-804-3000
  • Fax: 817-334-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number713757
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number713757
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: