Provider Demographics
NPI:1154399087
Name:ROMAN, TIMOTHY A (CRNA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:A
Last Name:ROMAN
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 1:409 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-2617
Mailing Address - Country:US
Mailing Address - Phone:830-997-8579
Mailing Address - Fax:830-997-9226
Practice Address - Street 1:415 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4636
Practice Address - Country:US
Practice Address - Phone:830-997-9170
Practice Address - Fax:830-997-9226
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX725766367500000X
TXRN725766367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178684002Medicaid
TX1786840Medicaid
TX8606UAOtherBLUE CROSS BLUE SHIELD
TX86079UOtherBCBS TX
TX86079UOtherBCBS TX
TX8606UAOtherBLUE CROSS BLUE SHIELD