Provider Demographics
NPI:1568553436
Name:HAVLICEK, GARY (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:HAVLICEK
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 1:3050 E AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2404
Mailing Address - Country:US
Mailing Address - Phone:562-426-9661
Mailing Address - Fax:562-426-4227
Practice Address - Street 1:165 N CLARK ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2108
Practice Address - Country:US
Practice Address - Phone:559-233-8657
Practice Address - Fax:559-233-0990
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN2565630OtherMEDI-CAL