Provider Demographics
NPI:1659397057
Name:ILLYES, PAUL RICHARD (CRNA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:RICHARD
Last Name:ILLYES
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 1:700 LIVE OAK DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541-7272
Mailing Address - Country:US
Mailing Address - Phone:501-827-4968
Mailing Address - Fax:
Practice Address - Street 1:700 LIVE OAK DR
Practice Address - Street 2:ANESTHESIA DEPT.
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-7272
Practice Address - Country:US
Practice Address - Phone:501-827-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0028011367500000X
TX507123367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115061701Medicaid
AR115061701Medicaid