Basic Information
| Provider Information | |||||||||
| NPI: | 1205866431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | KAMANAO'LANA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7912 E 31ST CT | ||||||||
| Address2: | STE 210 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741451315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183924477 | ||||||||
| FaxNumber: | 9183924465 | ||||||||
| Practice Location | |||||||||
| Address1: | 8801 S 101 E AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182944915 | ||||||||
| FaxNumber: | 9182944947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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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 | R0084773 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 010672601002 | 01 | OK | BCBSOK | OTHER | 200091050A | 05 | OK | MEDICAID |