Basic Information
| Provider Information | |||||||||
| NPI: | 1609013929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINCAID THOMAS | ||||||||
| FirstName: | TANGY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KINCAID | ||||||||
| OtherFirstName: | TANGY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 419 TOP HILL DR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757033678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012788674 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035314500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2009 | ||||||||
| LastUpdateDate: | 05/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 777455 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AP117858 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8KP516 | 01 | TX | BCBS | OTHER | P02210578 | 01 | TX | MEDICARE RAIL ROAD | OTHER | 777455 | 01 | TX | BCBS | OTHER | 202731002 | 05 | TX | MEDICAID | 202731008 | 05 | TX | MEDICAID |