Provider Demographics
NPI:1811974009
Name:CADAMBI, AVANTIKA (CRNA)
Entity type:Individual
Prefix:MS
First Name:AVANTIKA
Middle Name:
Last Name:CADAMBI
Suffix:
Gender:F
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 11219
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0219
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:817-294-7172
Practice Address - Street 1:957 MONARCH WAY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-5266
Practice Address - Country:US
Practice Address - Phone:817-562-4879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX617986163W00000X
TX051958367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0031031-09Medicaid
TX003103107Medicaid
8473UAOtherBCBS
8473UAOtherBCBS
P22893Medicare UPIN
TX003103107Medicaid
TX8K7439Medicare PIN
TX0031031-09Medicaid
TX8D7256Medicare ID - Type Unspecified607K