Healthcare Provider Details

I. General information

NPI: 1265894638
Provider Name (Legal Business Name): CHARLES BEAUDOIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST MS8182
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

3601 4TH ST MS8182
LUBBOCK TX
79430-0002
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-9945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP130640
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: