Provider Demographics
NPI:1104463868
Name:USSERY, DAMON ROAN JR (CRNA)
Entity type:Individual
Prefix:MR
First Name:DAMON
Middle Name:ROAN
Last Name:USSERY
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:6606 LBJ FWY STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6524
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-386-2155
Practice Address - Street 1:1301 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2122
Practice Address - Country:US
Practice Address - Phone:817-250-3683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXAP144544367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX803178OtherRN STATE LIC