Basic Information
| Provider Information | |||||||||
| NPI: | 1730289034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOGARTY | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 21 NE 3RD ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731042205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024867115 | ||||||||
| FaxNumber: | 4024346047 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 NE 3RD ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731042205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024867115 | ||||||||
| FaxNumber: | 4024346047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R0046631 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 100782930A | 05 | OK | MEDICAID |