Healthcare Provider Details

I. General information

NPI: 1518166347
Provider Name (Legal Business Name): BRYAN C SPEARS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 12/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 E CHERRY
CUSHING OK
74023-4101
US

IV. Provider business mailing address

1145 S UTICA AVE SUITE 110
TULSA OK
74104-4013
US

V. Phone/Fax

Practice location:
  • Phone: 918-225-8258
  • Fax: 918-225-8122
Mailing address:
  • Phone: 918-579-3825
  • Fax: 918-579-1262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number41360912
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209006700
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number91028
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number91028
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: