Provider Demographics
NPI:1932335460
Name:BERSOLA, JEATHRINA
Entity Type:Individual
Prefix:
First Name:JEATHRINA
Middle Name:
Last Name:BERSOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRINA
Other - Middle Name:
Other - Last Name:BERSOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
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:972-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:1500 CITYWEST BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2300
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:713-458-4229
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP118669367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211163501Medicaid
TX8048UAOtherBLUE CROSS BLUE SHIELD
TXP00826712OtherRAILROAD MEDICARE
TX8L25965Medicare PIN