Provider Demographics
NPI:1063739035
Name:LAQUA, TRAVIS DEAN (CRNA)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DEAN
Last Name:LAQUA
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 1:6431 FANNIN ST # 5.020
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:713-500-6200
Mailing Address - Fax:
Practice Address - Street 1:6411 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-500-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX717765367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213549313Medicaid
TX8497UQOtherBCBS
TX8497UQOtherBCBS