Basic Information
| Provider Information | |||||||||
| NPI: | 1437118775 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEATHERFORD ANESTHESIA ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 163694 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761613694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889911101 | ||||||||
| FaxNumber: | 9037875854 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 EUREKA ST | ||||||||
| Address2: | STE B | ||||||||
| City: | WEATHERFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760865880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175988150 | ||||||||
| FaxNumber: | 8175994902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | HARMER | ||||||||
| AuthorizedOfficialFirstName: | JON-PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8175994901 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 143321101 | 05 | TX | MEDICAID |