Provider Demographics
NPI:1477791259
Name:OSTHEIMER, MARIE LATIOLAIS (CRNA)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:LATIOLAIS
Last Name:OSTHEIMER
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 1:2901 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5128
Mailing Address - Country:US
Mailing Address - Phone:903-758-1818
Mailing Address - Fax:
Practice Address - Street 1:2901 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5128
Practice Address - Country:US
Practice Address - Phone:903-758-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-01
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEMP367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201365801Medicaid
TX201365801Medicaid