Provider Demographics
NPI:1407955594
Name:CHISHOLM, ALEX G (CRNA)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:G
Last Name:CHISHOLM
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:PO BOX 4157
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79704-4157
Mailing Address - Country:US
Mailing Address - Phone:432-520-0291
Mailing Address - Fax:432-520-2181
Practice Address - Street 1:2706 W CUTHBERT AVE
Practice Address - Street 2:BUILDING B, STE 100
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-3885
Practice Address - Country:US
Practice Address - Phone:432-520-0291
Practice Address - Fax:432-520-2181
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX552620367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR69952Medicare UPIN
TX8B9045Medicare ID - Type Unspecified