Healthcare Provider Details

I. General information

NPI: 1023592805
Provider Name (Legal Business Name): IVAN KOZHULENKO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 STANTON L YOUNG BLVD STE WP1140
OKLAHOMA CITY OK
73104-5036
US

IV. Provider business mailing address

PO BOX 26901
OKLAHOMA CITY OK
73126-0901
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4351
  • Fax: 405-271-8695
Mailing address:
  • Phone: 405-271-4351
  • Fax: 405-271-8695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number127368
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: