Provider Demographics
NPI:1881638419
Name:RODGERS, TERESE B (CRNA)
Entity Type:Individual
Prefix:
First Name:TERESE
Middle Name:B
Last Name:RODGERS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:MARIE
Other - Last Name:BRADWAY
Other - Suffix:
Other - Last Name Type:Other 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:
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:77042-2549
Practice Address - Country:US
Practice Address - Phone:972-233-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX587427367500000X
TXAP104652367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149365201Medicaid
TXP00606660OtherMEDICARE RAILROAD
TX85275UOtherBLUE CROSS PROVIDER ID
TX149365201Medicaid
86056HMedicare ID - Type Unspecified