Provider Demographics
NPI:1023057239
Name:DUBOSE, RUSSELL E (CRNA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:E
Last Name:DUBOSE
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 1219
Mailing Address - Street 2:
Mailing Address - City:BURNET
Mailing Address - State:TX
Mailing Address - Zip Code:78611-7219
Mailing Address - Country:US
Mailing Address - Phone:512-715-3000
Mailing Address - Fax:512-756-6405
Practice Address - Street 1:3201 S WATER ST
Practice Address - Street 2:
Practice Address - City:BURNET
Practice Address - State:TX
Practice Address - Zip Code:78611-4510
Practice Address - Country:US
Practice Address - Phone:512-715-3000
Practice Address - Fax:512-756-6405
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX248885367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220520501OtherMEDICAID PIN - GROUP
TX00405ROtherMEDICARE PIN - GROUP
TX86121HMedicare PIN