Healthcare Provider Details

I. General information

NPI: 1740218866
Provider Name (Legal Business Name): JASON SHANE BRUCE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MORRIS DR
OKMULGEE OK
74447-6429
US

IV. Provider business mailing address

18162 OLD MORRIS HWY
OKMULGEE OK
74447
US

V. Phone/Fax

Practice location:
  • Phone: 918-756-3177
  • Fax:
Mailing address:
  • Phone: 918-733-9824
  • Fax: 918-733-9825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 0085091
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2004003392
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: