Provider Demographics
NPI:1508838459
Name:TYDLASKA, JASON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:TYDLASKA
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 1:1832 CROOKED LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-4509
Mailing Address - Country:US
Mailing Address - Phone:817-496-0749
Mailing Address - Fax:817-496-0424
Practice Address - Street 1:4509 LEMMON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-2145
Practice Address - Country:US
Practice Address - Phone:214-692-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-05
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX630385367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered