Provider Demographics
NPI:1902349566
Name:YEZAK, MELVIN II (CRNA)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:YEZAK
Suffix:II
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 1:1737 BRIARCREST DR
Mailing Address - Street 2:STE 14
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2769
Mailing Address - Country:US
Mailing Address - Phone:979-776-4777
Mailing Address - Fax:979-776-0588
Practice Address - Street 1:1737 BRIARCREST DR
Practice Address - Street 2:STE 14
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2769
Practice Address - Country:US
Practice Address - Phone:979-776-4777
Practice Address - Fax:979-776-4777
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX810704367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX366260301Medicaid
TX366260301Medicaid