Provider Demographics
NPI:1962400069
Name:LAGODA, JEANINE MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:MARIE
Last Name:LAGODA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JEANINE
Other - Middle Name:MARIE
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2411 FOUNTAIN VIEW DR.
Mailing Address - Street 2:STE. 200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-4817
Mailing Address - Country:US
Mailing Address - Phone:713-620-4000
Mailing Address - Fax:
Practice Address - Street 1:2411 FOUNTAIN VIEW DR.
Practice Address - Street 2:STE. 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4817
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX615226367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01095287OtherRAILROAD MEDICARE
TX8164UBOtherBLUE CROSS BLUE SHIELD
TX84854UMedicare ID - Type UnspecifiedGRPC52T
TX8164UBOtherBLUE CROSS BLUE SHIELD