Healthcare Provider Details

I. General information

NPI: 1851347546
Provider Name (Legal Business Name): TIMOTHY D SHIELDS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 N COMMERCE ST
ARDMORE OK
73401-1356
US

IV. Provider business mailing address

PO BOX 5978
ARDMORE OK
73403-0978
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-5000
  • Fax: 580-226-5035
Mailing address:
  • Phone: 580-226-5000
  • Fax: 580-226-5035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0064541
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: