Healthcare Provider Details

I. General information

NPI: 1194721159
Provider Name (Legal Business Name): ROBERT EUGENE ROSE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6839 S CANTON AVE
TULSA OK
74136-3402
US

IV. Provider business mailing address

12202 E OAK DR
CLAREMORE OK
74019-5684
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-0612
  • Fax:
Mailing address:
  • Phone: 918-342-0314
  • Fax: 918-481-5170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberR0044766
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number44766
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: