Provider Demographics
NPI:1285664367
Name:JEWELL, LARRY (CRNA RRT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:JEWELL
Suffix:
Gender:M
Credentials:CRNA RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-5909
Mailing Address - Country:US
Mailing Address - Phone:903-891-7000
Mailing Address - Fax:903-893-5334
Practice Address - Street 1:500 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7354
Practice Address - Country:US
Practice Address - Phone:903-891-7000
Practice Address - Fax:903-893-5334
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX566292367500000X
TX24291227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86720COtherBLUE CROSS BLUE SHIELD
TX130161603Medicaid
TX89624UOtherBCBS (PINNACLE)
TX430028470OtherRAILROAD MEDICARE
TX86720COtherBLUE CROSS BLUE SHIELD
TX89624UOtherBCBS (PINNACLE)
TX430028470OtherRAILROAD MEDICARE