=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033470067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEITH W MCDONALD CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2012
-----------------------------------------------------
Last Update Date | 03/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18511 HIGHLANDER MEDICS ST
-----------------------------------------------------
City | FORT BLISS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79906-5327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-742-9897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6721 EL PARQUE DR
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79912-7309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-208-0186
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | AP128659
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 2011040881
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------