MEDICARE: HOWARD DWAYNE CREDOR CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN074876	LA
2	367500000X	Certified Registered Nurse Anesthetist	704230	TX
3	367500000X	Certified Registered Nurse Anesthetist	AP113139	TX

General Provider Information

NPI Number	:	1154376721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOWARD DWAYNE CREDOR CRNA

Provider Business Mailing Address
First Line	:	7946 N LOOP 1604 W
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-5174
Country	:	US
Telephone Number	:	210-567-9100
Fax Number	:	210-450-2165

Provider Business Practice Location Address
First Line	:	7946 N LOOP 1604 W
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-5174
Country	:	US
Telephone Number	:	210-567-9100
Fax Number	:	210-450-2165

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	10/11/2024

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