Provider Demographics
NPI:1669459285
Name:HUDDLESTON, THOMAS KEVIN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:KEVIN
Last Name:HUDDLESTON
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:PO BOX 650866
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0866
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:6606 LBJ FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6524
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249299367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82641UOtherBCBS
TX119962207Medicaid
TX119962205Medicaid
TX119962206Medicaid
TX82641UOtherBCBS
TX8A0811Medicare ID - Type Unspecified606K
TX119962205Medicaid
TX8883B8Medicare PIN
TX8A0812Medicare ID - Type Unspecified607K
TX119962207Medicaid
TX8883B8Medicare ID - Type Unspecified339K