Basic Information
| Provider Information | |||||||||
| NPI: | 1427150812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORDECAI | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1664 | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744021664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059478585 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 ROCKEFELLER DR | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744015075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186842557 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | R0032436 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1721794 | 05 | LA | MEDICAID |