Provider Demographics
NPI:1033239157
Name:INGMIRE, RANDY KEILICH (CRNA)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:KEILICH
Last Name:INGMIRE
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 1:10455 N CENTRAL EXPY
Mailing Address - Street 2:STE. 109-347
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-2213
Mailing Address - Country:US
Mailing Address - Phone:956-754-9687
Mailing Address - Fax:
Practice Address - Street 1:10455 N CENTRAL EXPY
Practice Address - Street 2:SUITE 109-347
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-2213
Practice Address - Country:US
Practice Address - Phone:956-754-9687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX646815367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89871UOtherBCBSTX
P00734852Medicare PIN
TX8L9880Medicare PIN