Healthcare Provider Details

I. General information

NPI: 1669937793
Provider Name (Legal Business Name): MATTHEW WOOD CUMMENS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2019
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3100
  • Fax:
Mailing address:
  • Phone: 918-458-3115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0101470
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: