Provider Demographics
NPI:1609013929
Name:KINCAID THOMAS, TANGY NICOLE (CRNA)
Entity Type:Individual
Prefix:
First Name:TANGY
Middle Name:NICOLE
Last Name:KINCAID THOMAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TANGY
Other - Middle Name:NICOLE
Other - Last Name:KINCAID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:419 TOP HILL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3678
Mailing Address - Country:US
Mailing Address - Phone:601-278-8674
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-531-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX777455367500000X
TXAP117858367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8KP516OtherBCBS
TXP02210578OtherMEDICARE RAIL ROAD
TX777455OtherBCBS
TX202731002Medicaid
TX202731008Medicaid