Provider Demographics
NPI:1730205535
Name:VICTORIAN, KIRK LANCE (CRNA)
Entity type:Individual
Prefix:MR
First Name:KIRK
Middle Name:LANCE
Last Name:VICTORIAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3899
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79923-3899
Mailing Address - Country:US
Mailing Address - Phone:915-577-0030
Mailing Address - Fax:915-533-2568
Practice Address - Street 1:2415 E. VANDELL DR
Practice Address - Street 2:SUIT B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3616
Practice Address - Country:US
Practice Address - Phone:915-577-0111
Practice Address - Fax:915-533-2568
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX718442367500000X
TXAP115614367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185664301Medicaid
TX87234UOtherBCBS
TXY22188Medicare UPIN
Y2218Medicare UPIN
TX8J6684Medicare PIN