Healthcare Provider Details

I. General information

NPI: 1548668627
Provider Name (Legal Business Name): PROFESSIONAL ANESTHESIOLOGY SURGICAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 E 15TH ST SUITE 102
TULSA OK
74104-5245
US

IV. Provider business mailing address

3333 E 77TH ST
TULSA OK
74136-8042
US

V. Phone/Fax

Practice location:
  • Phone: 918-935-3240
  • Fax: 918-935-3241
Mailing address:
  • Phone: 918-935-3240
  • Fax: 918-935-3241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25879
License Number StateOK

VIII. Authorized Official

Name: JAYEN H PATEL
Title or Position: OWNER
Credential: M.D.
Phone: 918-935-3240