Healthcare Provider Details

I. General information

NPI: 1902875479
Provider Name (Legal Business Name): RANDALL WATSON BRADY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 2ND AVE SW
MIAMI OK
74354-6830
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE 280
OKLAHOMA CITY OK
73112-5556
US

V. Phone/Fax

Practice location:
  • Phone: 918-542-6611
  • Fax: 918-787-3635
Mailing address:
  • Phone: 918-542-6611
  • Fax: 918-787-3635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0033098
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: