Provider Demographics
NPI:1407058597
Name:NGWA, CANDICE (CRNA)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:NGWA
Suffix:
Gender:F
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:PO BOX 650426
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0426
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:13737 NOEL ROAD
Practice Address - Street 2:STE 1400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-2004
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN187990367500000X
TX679506367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200394110AMedicaid
TX210184205Medicaid
TX8853UAOtherBLUE SHIELD
TX8853UAOtherBCBS
TX8853UAOtherBLUE CROSS
TXP00928962OtherRAILROAD
GA948795930AMedicaid
GA948795930BMedicaid
OK200394110AMedicaid