Provider Demographics
NPI:1043637838
Name:GIST, KEITH (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:GIST
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 4157
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79704-4157
Mailing Address - Country:US
Mailing Address - Phone:432-699-0225
Mailing Address - Fax:
Practice Address - Street 1:4519 N GARFIELD ST STE 15
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-3400
Practice Address - Country:US
Practice Address - Phone:432-699-0225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX758719367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered