Basic Information
| Provider Information | |||||||||
| NPI: | 1407825425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TATUM | ||||||||
| FirstName: | BILL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 963410 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731963410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057176800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 HEALTH CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730996381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057176800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
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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 | R0071233 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P00364317 | 01 | OK | RR MEDICARE | OTHER | 200020660A | 05 | OK | MEDICAID |