Healthcare Provider Details

I. General information

NPI: 1013284397
Provider Name (Legal Business Name): MICHAEL SEAN O'DELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N PORTLAND AVE
OKLAHOMA CITY OK
73112-2074
US

IV. Provider business mailing address

PO BOX 248875
OKLAHOMA CITY OK
73124-8875
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-6000
  • Fax:
Mailing address:
  • Phone: 918-392-2944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0067052
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: