Provider Demographics
NPI:1578676946
Name:PENDLETON, SAMUEL KYLE (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KYLE
Last Name:PENDLETON
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 1:189 LAKE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TUSCOLA
Mailing Address - State:TX
Mailing Address - Zip Code:79562-3662
Mailing Address - Country:US
Mailing Address - Phone:325-572-4097
Mailing Address - Fax:
Practice Address - Street 1:6250 US HIGHWAY 83
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5215
Practice Address - Country:US
Practice Address - Phone:325-428-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX674937367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87985UOtherBCBS
TX87985UOtherBCBS