Basic Information
| Provider Information | |||||||||
| NPI: | 1417393158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OWL ANESTHESIA APRN-CRNA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2502 ASHE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730345949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2769717319 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2825 PARKLAWN DR | ||||||||
| Address2: | MIDWEST REGIONAL MEDICAL CENTER | ||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053607576 | ||||||||
| FaxNumber: | 4053607762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | SAUNDERS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | ROBBIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2769717319 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APRN-CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 104163 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200418130A | 05 | OK | MEDICAID | OKAAA3389 | 01 | OK | MEDICARE PTAN | OTHER |