Healthcare Provider Details

I. General information

NPI: 1750529079
Provider Name (Legal Business Name): THOMAS R BENAFIELD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N 30TH ST
CLINTON OK
73601-3117
US

IV. Provider business mailing address

301 UNIVERSITY BLVD
GALVESTON TX
77555-5302
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-2363
  • Fax: 580-331-1484
Mailing address:
  • Phone: 409-772-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2677162
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP120163
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number103426
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: