Provider Demographics
NPI:1699870857
Name:BLUEBONNET ANESTHESIA SERVICES PC
Entity type:Organization
Organization Name:BLUEBONNET ANESTHESIA SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTDEGEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:830-237-2323
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:TX
Mailing Address - Zip Code:78648-1108
Mailing Address - Country:US
Mailing Address - Phone:830-237-2323
Mailing Address - Fax:830-875-2658
Practice Address - Street 1:600 N UNION AVE
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-4194
Practice Address - Country:US
Practice Address - Phone:830-237-2323
Practice Address - Fax:830-875-2658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX457349367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C85ROtherBLUE CROSS BLUE SHIELD
TX00646VMedicare ID - Type UnspecifiedMEDICARE