Healthcare Provider Details

I. General information

NPI: 1487985016
Provider Name (Legal Business Name): SERGIO GONZALEZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SERGIO GONZALEZ-CHAP

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 01/21/2010
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

1011 14TH AVE NW
ARDMORE OK
73401-1828
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-1251
  • Fax: 580-226-1254
Mailing address:
  • Phone: 580-226-1251
  • Fax: 580-226-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0075019
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: