Provider Demographics
NPI:1730545658
Name:COUTINO, ERASMO
Entity type:Individual
Prefix:MR
First Name:ERASMO
Middle Name:
Last Name:COUTINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 W BROADUS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-2410
Mailing Address - Country:US
Mailing Address - Phone:817-319-0545
Mailing Address - Fax:
Practice Address - Street 1:3001 BROADMOOR BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-2100
Practice Address - Country:US
Practice Address - Phone:817-319-0545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129935367500000X
NM75563367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered