Healthcare Provider Details

I. General information

NPI: 1578896833
Provider Name (Legal Business Name): ADAM LEE SHEPPARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 S WALKER AVE
OKLAHOMA CITY OK
73139-9475
US

IV. Provider business mailing address

508 CHEROKEE GATE DR
YUKON OK
73099-6153
US

V. Phone/Fax

Practice location:
  • Phone: 405-602-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number71103
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: