Basic Information
| Provider Information | |||||||||
| NPI: | 1639187131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALFORD | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4897 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037875850 | ||||||||
| FaxNumber: | 9037875854 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 E MOCKINGBIRD LN | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615736291 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 736013 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 84981U | 01 | TX | BLUE CROSS | OTHER | 171759701 | 05 | TX | MEDICAID |