Basic Information
| Provider Information | |||||||||
| NPI: | 1679568976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZAMORA | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4346 | ||||||||
| Address2: | DEPT 693 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813588114 | ||||||||
| FaxNumber: | 2813580609 | ||||||||
| Practice Location | |||||||||
| Address1: | 6801 EMMETT F LOWRY EXPY | ||||||||
| Address2: | |||||||||
| City: | TEXAS CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775912500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099385361 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 578697 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 047390 | 01 | TX | RECERTIFICATION AANA | OTHER | 465552276 | 01 | TX | TRICARE INSURANCE | OTHER | P00137889 | 01 | TX | RAILROAD MEDICARE | OTHER | 002981102 | 05 | TX | MEDICAID | 84610U | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |