Basic Information
| Provider Information | |||||||||
| NPI: | 1710975941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EZELL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840853 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 CITYWEST BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770422549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 051342 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AP110320 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 002965402 | 05 | TX | MEDICAID | 002965408 | 05 | TX | MEDICAID | 002965407 | 05 | TX | MEDICAID | 85650U | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |