MEDICARE: MS. SUSAN A MARTIN CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	R0072841	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	721545605 001	OTHER	OK	BCBS #
3	010672601002	OTHER	OK	BCBSOK

General Provider Information

NPI Number	:	1073515557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN A MARTIN CRNA

Provider Business Mailing Address
First Line	:	5807 S DELAWARE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-7329
Country	:	US
Telephone Number	:	918-742-2475
Fax Number	:	918-742-2194

Provider Business Practice Location Address
First Line	:	5807 S DELAWARE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-7329
Country	:	US
Telephone Number	:	918-742-2475
Fax Number	:	918-742-2194

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	10/29/2007

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