Basic Information
| Provider Information | |||||||||
| NPI: | 1003806464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVANG | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | FRED | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3719 COUNTY ROAD 131 | ||||||||
| Address2: | |||||||||
| City: | WHARTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774888535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7132525200 | ||||||||
| FaxNumber: | 9795631693 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 E MOCKINGBIRD LN | ||||||||
| Address2: | 101 | ||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615732481 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 08/05/2016 | ||||||||
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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 | 207L00000X | 642422 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | 642422 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 83842U | 01 | TX | BLUE CROSS/BLUE SHIELD | OTHER | 052983 | 01 | TX | RECERTIFICATION | OTHER | 151044802 | 05 | TX | MEDICAID | P00090293 | 01 | TX | RAILROAD MEDICARE | OTHER |