Basic Information
| Provider Information | |||||||||
| NPI: | 1386880847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURCIU | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | MONICA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TOFANEL | ||||||||
| OtherFirstName: | AMELIA | ||||||||
| OtherMiddleName: | MONICA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 840853 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331999 | ||||||||
| FaxNumber: | 9722333666 | ||||||||
| Practice Location | |||||||||
| Address1: | 4916 OVERTON PLZ | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888043000 | ||||||||
| FaxNumber: | 8178770899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2009 | ||||||||
| LastUpdateDate: | 06/04/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 679908 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | PENDING | 05 | TX | MEDICAID |