Provider Demographics
NPI:1508848839
Name:ACOSTA, ANTONIO R (DNP, APRN, CRNA, NSP)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:R
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:DNP, APRN, CRNA, NSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9934 HUBBLE DR
Mailing Address - Street 2:
Mailing Address - City:IOWA COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:77583-1503
Mailing Address - Country:US
Mailing Address - Phone:832-920-6451
Mailing Address - Fax:
Practice Address - Street 1:387 W INTERSTATE 10
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735-2708
Practice Address - Country:US
Practice Address - Phone:432-336-2004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX677410367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1710576-02Medicaid
TX1710576-02Medicaid
Q35165Medicare UPIN
P00400156Medicare PIN