Provider Demographics
NPI:1336139716
Name:SMITH, CAROL ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:KLAVONICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2549
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:713-458-4229
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX458908207L00000X, 367500000X
TXAP100766367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX023780OtherRECERTIFICATION
TX430068751OtherRAILROAD MEDICARE
TX002846602Medicaid
TX002846606Medicaid
TX83010LLOtherBLUE CROSS/BLUE SHIELD
TX002846607Medicaid
R69960Medicare UPIN
TXTXB119021Medicare UPIN
TX002846602Medicaid