Provider Demographics
NPI:1124583430
Name:KELLUM, MICAH (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:
Last Name:KELLUM
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 1:30711 SPANISH MOSS XING
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-3709
Mailing Address - Country:US
Mailing Address - Phone:713-560-9519
Mailing Address - Fax:
Practice Address - Street 1:18500 KATY FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77094-1110
Practice Address - Country:US
Practice Address - Phone:832-522-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140431367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered