Provider Demographics
NPI:1003952185
Name:BOATMAN, TERRY DEAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:DEAN
Last Name:BOATMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1049
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-1049
Mailing Address - Country:US
Mailing Address - Phone:903-799-3000
Mailing Address - Fax:
Practice Address - Street 1:1007 S WILLIAM ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-3245
Practice Address - Country:US
Practice Address - Phone:903-799-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX657228367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81648UOtherBLUE CROSS BLUE SHEILD
TX143828501Medicaid
TX143828501Medicaid
TX430067992Medicare ID - Type UnspecifiedRAILROAD MEDICARE