Basic Information
| Provider Information | |||||||||
| NPI: | 1942234505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NODERER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 GATEWAY BLVD W | ||||||||
| Address2: | STE. 120 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157791716 | ||||||||
| FaxNumber: | 9157716558 | ||||||||
| Practice Location | |||||||||
| Address1: | 5959 GATEWAY BLVD W | ||||||||
| Address2: | STE. 120 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157791716 | ||||||||
| FaxNumber: | 9157716558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/06/2008 | ||||||||
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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 | 718467 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 85538U | 01 | TX | BCBS | OTHER | 178300301 | 05 | TX | MEDICAID |