Healthcare Provider Details

I. General information

NPI: 1457539454
Provider Name (Legal Business Name): JAMES KETTERMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 S 5TH ST
ENID OK
73701-5832
US

IV. Provider business mailing address

305 S 5TH ST
ENID OK
73701-5832
US

V. Phone/Fax

Practice location:
  • Phone: 580-233-6100
  • Fax:
Mailing address:
  • Phone: 580-233-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN71292
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: