Provider Demographics
NPI:1235496217
Name:ABRAHAM, DUSTIN J (CRNA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:J
Last Name:ABRAHAM
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 1:6580 JUDSON RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7076
Mailing Address - Country:US
Mailing Address - Phone:903-663-3600
Mailing Address - Fax:214-382-5417
Practice Address - Street 1:6580 JUDSON RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7076
Practice Address - Country:US
Practice Address - Phone:903-663-3600
Practice Address - Fax:214-382-5417
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK105075367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered