Provider Demographics
NPI:1548438138
Name:MOLINA, MAURO ALBERTO (CRNA)
Entity type:Individual
Prefix:
First Name:MAURO
Middle Name:ALBERTO
Last Name:MOLINA
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:PO BOX 650426
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0426
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-5015
Practice Address - Street 1:13601 PRESTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-4911
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-5015
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX698320367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192251002Medicaid
TX88716UOtherBLUE CROSS BLUE SHIELD
TX192251001Medicaid
TX89610UOtherBCBS
TX88716UOtherBLUE CROSS BLUE SHIELD
TX192251001Medicaid