Provider Demographics
NPI:1326050089
Name:THIBODEAUX, BARRY LYNN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:LYNN
Last Name:THIBODEAUX
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 1:1463 SE LOOP 456
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-9184
Mailing Address - Country:US
Mailing Address - Phone:903-589-1150
Mailing Address - Fax:
Practice Address - Street 1:1463 SE LOOP 456
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-9184
Practice Address - Country:US
Practice Address - Phone:903-589-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX590631367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered