Provider Demographics
NPI:1285909143
Name:ELLIS, MEREDITH BORDELON (CRNA)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:BORDELON
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:BARNES
Other - Last Name:BORDELON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2549
Practice Address - Country:US
Practice Address - Phone:972-233-1999
Practice Address - Fax:972-233-3666
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN117385367500000X
LAAP06757367500000X
TXAP133877367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered