Provider Demographics
NPI:1457603920
Name:AGUAYO, MARIO LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:LEE
Last Name:AGUAYO
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 27476
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0476
Mailing Address - Country:US
Mailing Address - Phone:806-743-3492
Mailing Address - Fax:806-743-3576
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:1B350K
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-2981
Practice Address - Fax:806-743-2984
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX686698163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse