Basic Information
| Provider Information | |||||||||
| NPI: | 1851372734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTRAND | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MICKLEY | ||||||||
| OtherFirstName: | ANITA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2411 FOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770574817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2411 FOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770574817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 644316 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8637UA | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 82949U | 01 | TX | BLUE CROSS/BLUE SHIELD | OTHER | 8654UU | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | P00905289 | 01 | TX | RAILROAD MEDICARE | OTHER | 002975306 | 05 | TX | MEDICAID | 2169581 | 05 | LA | MEDICAID | 002975305 | 05 | TX | MEDICAID | 430078988 | 01 | TX | RAILROAD MEDICARE | OTHER | 002975302 | 05 | TX | MEDICAID | 050595 | 01 | TX | AANA RECERTIFICATION | OTHER |