Provider Demographics
NPI:1063594638
Name:BANDALAN, HAROLD RICHIE (CRNA)
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:RICHIE
Last Name:BANDALAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 8027
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-8027
Mailing Address - Country:US
Mailing Address - Phone:903-526-1068
Mailing Address - Fax:903-593-4290
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-526-1068
Practice Address - Fax:903-593-4290
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX671921367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141704005Medicaid
TX141704006Medicaid
TX8649UAOtherBCBS
TX86184UOtherBCBS OF TEXAS
TXP00288096OtherPART B RAILROAD MEDICARE
TXTXB111815Medicare PIN
TX141704005Medicaid
TX8F1919Medicare PIN