Basic Information
| Provider Information | |||||||||
| NPI: | 1760490015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN OAKS ANESTHESIA ASSOC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2065 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727452065 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5501 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731122074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186649892 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 02/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | A | ||||||||
| AuthorizedOfficialFirstName: | K | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3340000000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100729270A | 05 | OK | MEDICAID |