Provider Demographics
NPI:1083685150
Name:EVERSLEY, RICARDO B (CRNA)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:B
Last Name:EVERSLEY
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 2127
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-7127
Mailing Address - Country:US
Mailing Address - Phone:903-675-3202
Mailing Address - Fax:903-677-5586
Practice Address - Street 1:510 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3410
Practice Address - Country:US
Practice Address - Phone:903-675-3202
Practice Address - Fax:903-677-5586
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX680403367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1667891-02Medicaid
TX166789104Medicaid
8L12973Medicare PIN
8G0830Medicare PIN
P00278573Medicare PIN
TX8L22558Medicare PIN