Provider Demographics
NPI:1053470138
Name:EWING, KYLE E (CRNA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:E
Last Name:EWING
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 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:4916 OVERTON PLZ
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109
Practice Address - Country:US
Practice Address - Phone:888-804-3000
Practice Address - Fax:817-334-0235
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX630008367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C17YOtherBLUE CROSS BLUE SHIELD
TX156081505Medicaid
TX8122UUOtherBCBS
TX156081503Medicaid
TX156081503Medicaid
TX156081505Medicaid
TX8L13294Medicare PIN