Provider Demographics
NPI:1891798781
Name:DAIGLE, ROLAND REESE (CRNA)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:REESE
Last Name:DAIGLE
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 1:1105 E GOLIAD AVE
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-2230
Mailing Address - Country:US
Mailing Address - Phone:936-544-4996
Mailing Address - Fax:936-544-4244
Practice Address - Street 1:1105 E GOLIAD AVE
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-2230
Practice Address - Country:US
Practice Address - Phone:936-544-4996
Practice Address - Fax:936-544-4244
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX512552367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84893UOtherBCBSTX
TX88726UOtherBCBS
TX137813514Medicaid
TX137813512Medicaid
TX137813519Medicaid
TXR14723Medicare UPIN
TX137813512Medicaid
TX137813514Medicaid
TX83952HMedicare PIN