Provider Demographics
NPI:1225066806
Name:YAKICH, THOMAS PETER (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PETER
Last Name:YAKICH
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 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:915-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:6606 LBJ FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6533
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX633892367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82241UOtherBLUE CROSS BLUE SHIELD
OK100781430AMedicaid
TX430067372OtherRAILROAD MEDICARE
TX8821UGOtherBCBS
TXP01446790OtherRR
TX146490101Medicaid
TX146490104Medicaid
TX363271YK6UMedicare PIN
OK100781430AMedicaid
TX82241UOtherBLUE CROSS BLUE SHIELD
TXTXB119203Medicare PIN