Provider Demographics
NPI:1104099209
Name:RATHBUN, PERRY A (CRNA)
Entity type:Individual
Prefix:
First Name:PERRY
Middle Name:A
Last Name:RATHBUN
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 1:510 E CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3410
Mailing Address - Country:US
Mailing Address - Phone:903-677-1000
Mailing Address - Fax:903-677-1694
Practice Address - Street 1:510 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3410
Practice Address - Country:US
Practice Address - Phone:903-677-1000
Practice Address - Fax:903-677-1694
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO122180367500000X
TX871224367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO916904261Medicaid
TX391676YNM4Medicare PIN
TX391676YNR7Medicare PIN
MO817074008Medicare PIN