Basic Information
| Provider Information | |||||||||
| NPI: | 1013284397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'DELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SEAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 248875 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731248875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183922944 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5501 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731122074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056046000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2011 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R0067052 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200421920A | 05 | OK | MEDICAID |