Provider Demographics
NPI:1609384056
Name:RICHARDSON, MATTHEW (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RICHARDSON
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 1:3131 MYRTLE GROVE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-1228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7010 CHAMPIONS PLAZA DR STE 400
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77069-2395
Practice Address - Country:US
Practice Address - Phone:832-698-5331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX932787367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered