Provider Demographics
NPI:1558615880
Name:MORDECAI, ANGELA (CRNA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MORDECAI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:AVANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:6606 LBJ FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6524
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2012-11-08
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX766754367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX317029201Medicaid
TX317029202Medicaid
TXP01172780OtherRAILROAD
TX8817UDOtherBCBS
TX8682UGOtherBCBS TX
TXP01172780OtherRAILROAD
TX267102YK9HMedicare PIN