MEDICARE: MICHAEL DEAN WITHROW 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	R0054495	OK

General Provider Information

NPI Number	:	1629163126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL DEAN WITHROW CRNA

Provider Business Mailing Address
First Line	:	26 HILLCREST DR.
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604
Country	:	US
Telephone Number	:	580-304-3881
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 FAIRVIEW AVE
Second Line	:	SUITE 50
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1920
Country	:	US
Telephone Number	:	580-762-0695
Fax Number	:

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/22/2009

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