Provider Demographics
NPI:1699857755
Name:MIKOLAJEK, JEFFREY A (RN, CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:MIKOLAJEK
Suffix:
Gender:M
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 FOUNTAIN VIEW DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-4817
Mailing Address - Country:US
Mailing Address - Phone:713-620-4000
Mailing Address - Fax:
Practice Address - Street 1:2411 FOUNTAIN VIEW DR
Practice Address - Street 2:STE. 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4817
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX444586367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8893UAOtherBLUE CROSS BLUE SHIELD
TX002698102Medicaid
TX002698103Medicaid
TXTXB119178Medicare PIN
TX8893UAOtherBLUE CROSS BLUE SHIELD
TX002698102Medicaid