Provider Demographics
NPI:1760510119
Name:IEYOUB, MICHAEL JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:IEYOUB
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 1:608 STRICKLAND DR
Mailing Address - Street 2:DEPT OF ANESTHESIA
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-4717
Mailing Address - Country:US
Mailing Address - Phone:409-883-1303
Mailing Address - Fax:
Practice Address - Street 1:950 N 14TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1112
Practice Address - Country:US
Practice Address - Phone:409-833-5858
Practice Address - Fax:855-543-5077
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX560932367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C1903Medicare ID - Type Unspecified