Provider Demographics
NPI:1851335814
Name:HARTDEGEN, NICKY (CRNA)
Entity Type:Individual
Prefix:
First Name:NICKY
Middle Name:
Last Name:HARTDEGEN
Suffix:
Gender:F
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 1108
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:TX
Mailing Address - Zip Code:78648-1108
Mailing Address - Country:US
Mailing Address - Phone:830-875-6786
Mailing Address - Fax:830-875-6790
Practice Address - Street 1:101 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1847
Practice Address - Country:US
Practice Address - Phone:956-632-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX457349367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137810112Medicaid
TX3657500000XOtherTAXONOMY CODE
TX160955401Medicaid
TX00C85ROtherBCBS GRP NUMBER
TN82882UOtherBCBS
TX457349OtherCRNA LICENSE
TN82882UOtherBCBS
TX3657500000XOtherTAXONOMY CODE
TX8B1064Medicare ID - Type UnspecifiedTRAILBLAZER HEALTH