MEDICARE: TAMSAK KANOKLUKUL 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	367500000X	Certified Registered Nurse Anesthetist	560268	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639177462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMSAK KANOKLUKUL CRNA

Provider Business Mailing Address
First Line	:	PO BOX 844658
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4658
Country	:	US
Telephone Number	:	254-724-8800
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 HILLCREST MEDICAL BLVD
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-8897
Country	:	US
Telephone Number	:	254-202-5800
Fax Number	:	254-202-5849

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

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	11/16/2020

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