Basic Information
| Provider Information | |||||||||
| NPI: | 1770582736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 TURNER DR | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756016750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037201459 | ||||||||
| FaxNumber: | 9037201459 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 WILSON ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756525956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036577541 | ||||||||
| FaxNumber: | 9035967541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 04/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 47045 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 85006U | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 088614504 | 05 | TX | MEDICAID |