Provider Demographics
NPI:1275549396
Name:VASQUEZ, ESTEBAN (CRNA)
Entity Type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:
Last Name:VASQUEZ
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 1:2618 BRETTON RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-5322
Mailing Address - Country:US
Mailing Address - Phone:940-689-0103
Mailing Address - Fax:
Practice Address - Street 1:1600 11TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4300
Practice Address - Country:US
Practice Address - Phone:940-764-7000
Practice Address - Fax:940-764-3391
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX620664367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered