Healthcare Provider Details

I. General information

NPI: 1245738145
Provider Name (Legal Business Name): TREY RYAN ROUNDTREE APRN-CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 14TH AVE NW
ARDMORE OK
73401-1828
US

IV. Provider business mailing address

729 DOLESE RD
ARDMORE OK
73401-7578
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-5400
  • Fax:
Mailing address:
  • Phone: 580-513-4732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number99885
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: