Healthcare Provider Details

I. General information

NPI: 1194824136
Provider Name (Legal Business Name): LEROY ANTHONY DOMINO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BLOSSOM ST
WEBSTER TX
77598-4204
US

IV. Provider business mailing address

PO BOX 650859 DEPT 710
DALLAS TX
75265-7773
US

V. Phone/Fax

Practice location:
  • Phone: 832-632-6372
  • Fax:
Mailing address:
  • Phone: 409-747-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number663623
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP114089
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: