Basic Information
| Provider Information | |||||||||
| NPI: | 1003839911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PREMO | ||||||||
| FirstName: | BILLY | ||||||||
| MiddleName: | JACK | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10979 | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731401979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053607576 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2825 PARKLAWN DR | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053607576 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 03/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R0025846 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 430001523 | 01 | OK | MEDICARE PIN | OTHER | 731189454001 | 01 | OK | BCBS | OTHER | 100781950A | 05 | OK | MEDICAID |