Provider Demographics
NPI:1275922767
Name:ROYALL, MATTIE MCCLINTOCK (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:MCCLINTOCK
Last Name:ROYALL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MATTIE
Other - Middle Name:
Other - Last Name:MCCLINTOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 2127
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-7127
Mailing Address - Country:US
Mailing Address - Phone:903-677-1000
Mailing Address - Fax:903-677-1694
Practice Address - Street 1:3705 MEDICAL PKWY STE 570
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1024
Practice Address - Country:US
Practice Address - Phone:512-454-2554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX776975367500000X
TXAP127307367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered