Provider Demographics
NPI:1740244458
Name:AULTMAN, TATYANA (CRNA)
Entity type:Individual
Prefix:MRS
First Name:TATYANA
Middle Name:
Last Name:AULTMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TATYANA
Other - Middle Name:
Other - Last Name:BOGOMAZOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:6203 ROYAL RDG
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78239-1626
Mailing Address - Country:US
Mailing Address - Phone:509-939-9990
Mailing Address - Fax:
Practice Address - Street 1:6203 ROYAL RDG
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78239-1626
Practice Address - Country:US
Practice Address - Phone:509-939-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007033367500000X
TX812494367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered