Provider Demographics
NPI: | 1487855102 |
---|---|
Name: | MATEJKA, JEANNE RENEE (CRNA) |
Entity Type: | Individual |
Prefix: | |
First Name: | JEANNE |
Middle Name: | RENEE |
Last Name: | MATEJKA |
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 926098 |
Mailing Address - Street 2: | |
Mailing Address - City: | HOUSTON |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77292-6098 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 713-426-1669 |
Mailing Address - Fax: | 713-868-9416 |
Practice Address - Street 1: | 6200 SAVOY DR STE 150 |
Practice Address - Street 2: | |
Practice Address - City: | HOUSTON |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77036-3320 |
Practice Address - Country: | US |
Practice Address - Phone: | 713-426-1669 |
Practice Address - Fax: | 713-868-9416 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-05-30 |
Last Update Date: | 2011-06-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 016138 | 367500000X |
TX | 435864 | 163W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | |
No | 163W00000X | Nursing Service Providers | Registered Nurse |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 109930105 | Medicaid | |
TX | 83697U | Other | BCBS INDIVIDUAL PROV # |