Healthcare Provider Details

I. General information

NPI: 1679938922
Provider Name (Legal Business Name): PORTLAND ANESTHESIA ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N PORLAND AVE
OKLAHOMA CITY OK
73112
US

IV. Provider business mailing address

13737 NOEL RD STE 1600
DALLAS TX
75240-1374
US

V. Phone/Fax

Practice location:
  • Phone: 469-401-2386
  • Fax:
Mailing address:
  • Phone: 469-401-2386
  • 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: KATHY KONDAS
Title or Position: OFFICER
Credential:
Phone: 954-838-2371