Basic Information
| Provider Information | |||||||||
| NPI: | 1316917420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARREDONDO | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MSN, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7801 NW BRADY WAY | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735050600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103868008 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4301 MOW-WAY RD | ||||||||
| Address2: | RACH (ATTN:MCUA-QC, MS. PRESCOTT) | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804582134 | ||||||||
| FaxNumber: | 5804582314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 12/18/2017 | ||||||||
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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 | 0087300 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 0087300 | OK | N | Nursing Service Providers | Registered Nurse | 163W00000X | 648163 | TX | N | Nursing Service Providers | Registered Nurse | 367500000X | 648163 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200114700A | 05 | OK | MEDICAID |