Provider Demographics
NPI:1972777662
Name:CORDERO, JONATHAN M (CRNA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:CORDERO
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:PO BOX 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD
Practice Address - Street 2:STE. 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2300
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:713-458-4229
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP116556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195673202Medicaid
TX195673201Medicaid
TX89159UOtherBLUE CROSS BLUE SHIELD ID
TXP00698633OtherRAILROAD MEDICARE
TX89159UOtherBLUE CROSS BLUE SHIELD ID
TX00R518Medicare PIN
TXCI5380Medicare PIN
TX195673201Medicaid
TXP00698633OtherRAILROAD MEDICARE