Healthcare Provider Details

I. General information

NPI: 1841952397
Provider Name (Legal Business Name): SOUTHWESTERN OKLAHOMA SURGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5374 NW CACHE RD
LAWTON OK
73505-3313
US

IV. Provider business mailing address

5374 NW CACHE RD
LAWTON OK
73505-3313
US

V. Phone/Fax

Practice location:
  • Phone: 580-536-0000
  • Fax:
Mailing address:
  • Phone: 580-536-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHAWNA BYRD
Title or Position: CEO
Credential:
Phone: 580-536-0000