Provider Demographics
NPI:1083658546
Name:COLEMAN, ROBERT D (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:COLEMAN
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 1:1501 E MOCKINGBIRD LN STE 101
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2178
Mailing Address - Country:US
Mailing Address - Phone:361-573-6291
Mailing Address - Fax:361-576-2434
Practice Address - Street 1:815 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979
Practice Address - Country:US
Practice Address - Phone:361-573-6291
Practice Address - Fax:361-576-2434
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52733367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165728002Medicaid
TX165728002Medicaid
TX8C8899Medicare ID - Type Unspecified