Provider Demographics
NPI:1417983347
Name:BOUGHTON, PHILIP (CRNA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:BOUGHTON
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 1:2411 FOUNTAIN VIEW DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-4817
Mailing Address - Country:US
Mailing Address - Phone:713-620-4000
Mailing Address - Fax:
Practice Address - Street 1:2411 FOUNTAIN VIEW DR
Practice Address - Street 2:STE. 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4817
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN022007367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88837UOtherBLUE CROSS BLUE SHIELD
TXP00616409OtherMEDICARE RAILROAD
TX194156901Medicaid
TX8K7623Medicare PIN