Basic Information
| Provider Information | |||||||||
| NPI: | 1457524530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARRONE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | BROUSSARD | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840853 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
| FaxNumber: | 9727159976 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 CITYWEST BLVD | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770422300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | 7134584229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 746675 | TX | N | Nursing Service Providers | Registered Nurse | 367500000X | 079620 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AP116865 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 89147U | 01 | BLUE CROSS PROVIDER ID | OTHER | P00698628 | 01 | TX | RAILROAD MEDICARE | OTHER | 195782101 | 05 | TX | MEDICAID |