Provider Demographics
NPI:1689618787
Name:BAGWELL, ROMAN SHAWN (CRNA)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:SHAWN
Last Name:BAGWELL
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 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
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:2006-06-16
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX727514367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX186791301Medicaid
TX186791303Medicaid
TX86716UOtherBCBS
TXTIN PLUS 015OtherTRICARE
TX75-1976930-005OtherTRICARE
TXP01246266OtherRAIL ROAD
TX186791302Medicaid
TX8338UEOtherBCBS
TX75-1976930-005OtherTRICARE
TXTIN PLUS 015OtherTRICARE
TX8338UEOtherBCBS
TX8G9478Medicare Oscar/Certification