Basic Information
| Provider Information | |||||||||
| NPI: | 1548846009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOLEZAL | ||||||||
| FirstName: | MEAGAN | ||||||||
| MiddleName: | NICHOLE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2604 DUNCAN DR | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791093410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8066794637 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7100 W 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063559595 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2021 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 134949 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | TX | TEXAS MEDICARE | OTHER |