Provider Demographics
NPI:1689996860
Name:HAWTHORNE, MICA L (CRNA)
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:L
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MICA
Other - Middle Name:L
Other - Last Name:LAHAYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX778650367500000X
TXAP118700367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8049UAOtherBLUE CROSS BLUE SHIELD
TXP01046824OtherRAILROAD MEDICARE
LA2127187Medicaid
TX211464701Medicaid
TXP01046824OtherRAILROAD MEDICARE