Provider Demographics
NPI:1396851002
Name:VARGAS, GUSTAVO (CRNA)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:VARGAS
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 1:18058 DEER TRL
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-4000
Mailing Address - Country:US
Mailing Address - Phone:903-839-7874
Mailing Address - Fax:
Practice Address - Street 1:18058 DEER TRL
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:TX
Practice Address - Zip Code:75762-4000
Practice Address - Country:US
Practice Address - Phone:903-839-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP109346367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001740054Medicaid