Provider Demographics
NPI:1922092170
Name:SPRAGUE, PATI JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:PATI
Middle Name:JEAN
Last Name:SPRAGUE
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 1:2411 FOUNTAIN VIEW DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-4817
Mailing Address - Country:US
Mailing Address - Phone:713-620-4000
Mailing Address - Fax:
Practice Address - Street 1:2411 FOUNTAIN VIEW DR
Practice Address - Street 2:STE. 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4817
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX527947367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033360OtherRECERTIFICATION AANA
TX83818UOtherBLUE CROSS BLUE SHIELD
TXP00266404OtherRAILROAD MEDICARE
TX85288UOtherBLUE CROSS BLUE SHIELD
TX137819215Medicaid
TX137819216Medicaid
TX83818UOtherBLUE CROSS BLUE SHIELD
R69636Medicare UPIN
TX8F0071Medicare ID - Type Unspecified