Healthcare Provider Details

I. General information

NPI: 1174632152
Provider Name (Legal Business Name): KENNETH BATES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 W 6TH AVE
STILLWATER OK
74074-4306
US

IV. Provider business mailing address

PO BOX 720006
NORMAN OK
73070-4006
US

V. Phone/Fax

Practice location:
  • Phone: 405-372-1480
  • Fax:
Mailing address:
  • Phone: 405-372-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number120925
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1380744092
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: