Basic Information
Provider Information
NPI: 1033559992
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHAISSON
FirstName: GLAISE
MiddleName: JOHN
NamePrefix:  
NameSuffix: JR.
Credential: CRNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 650865
Address2:  
City: DALLAS
State: TX
PostalCode: 752650865
CountryCode: US
TelephoneNumber: 9722331999
FaxNumber: 9722333666
Practice Location
Address1: 1500 CITYWEST BLVD
Address2: STE. 300
City: HOUSTON
State: TX
PostalCode: 770422300
CountryCode: US
TelephoneNumber: 7136204000
FaxNumber: 7134584229
Other Information
ProviderEnumerationDate: 06/25/2013
LastUpdateDate: 02/23/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000XAP124073TXY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

ID Information
IDTypeStateIssuerDescription
32496250105TX MEDICAID
P0130405201TXRR MEDICAREOTHER
8229UF01TXBCBSOTHER


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