MEDICARE: MR. PHILIP NONE STREETMAN 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	R0023472	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	363399510002	OTHER	OK	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1760484133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILIP NONE STREETMAN CRNA

Provider Business Mailing Address
First Line	:	PO BOX 727
Second Line	:
City	:	POTEAU
State	:	OK
Zip	:	74953-0727
Country	:	US
Telephone Number	:	918-649-3426
Fax Number	:	918-649-3426

Provider Business Practice Location Address
First Line	:	500 POLK CREEK ST
Second Line	:
City	:	POTEAU
State	:	OK
Zip	:	74953-5420
Country	:	US
Telephone Number	:	918-649-3426
Fax Number	:	918-649-3426

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	11/12/2007

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