Provider Demographics
NPI:1225450711
Name:RASAVAGE, KEAL (CRNA)
Entity Type:Individual
Prefix:
First Name:KEAL
Middle Name:
Last Name:RASAVAGE
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 1:305 WILDCAT ST
Mailing Address - Street 2:
Mailing Address - City:WOLFFORTH
Mailing Address - State:TX
Mailing Address - Zip Code:79382-5326
Mailing Address - Country:US
Mailing Address - Phone:432-413-4601
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:8182
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-8182
Practice Address - Country:US
Practice Address - Phone:806-743-2981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX770256367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered