Provider Demographics
NPI:1396259263
Name:KURIAKOSE, NISHA MUCHAL (CRNA)
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:MUCHAL
Last Name:KURIAKOSE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NISHA
Other - Middle Name:
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:
Practice Address - Street 1:1500 CITYWEST BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042
Practice Address - Country:US
Practice Address - Phone:972-233-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN587182367500000X
TXAP138520367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX392230401Medicaid