Provider Demographics
NPI:1851315725
Name:VARDEMAN, ROBERT V (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:V
Last Name:VARDEMAN
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 1:15347 FM 1954
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-0370
Mailing Address - Country:US
Mailing Address - Phone:940-691-7034
Mailing Address - Fax:
Practice Address - Street 1:1600 11TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4300
Practice Address - Country:US
Practice Address - Phone:940-764-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX457293367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83772UOtherBCBSTX
TX8B8432Medicare PIN