Healthcare Provider Details

I. General information

NPI: 1467111005
Provider Name (Legal Business Name): PEDIATRIC ANESTHESIA OF OKLAHOMA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 12/10/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 BROADWAY EXT
OKLAHOMA CITY OK
73114-7408
US

IV. Provider business mailing address

PO BOX 248994
OKLAHOMA CITY OK
73124
US

V. Phone/Fax

Practice location:
  • Phone: 240-566-1600
  • Fax: 770-701-6718
Mailing address:
  • Phone: 240-566-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JORDAN STABINSKI
Title or Position: OWNER
Credential: MD
Phone: 240-566-1600