Healthcare Provider Details

I. General information

NPI: 1669496725
Provider Name (Legal Business Name): JASON P WHITELEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE
TULSA OK
74104-4012
US

IV. Provider business mailing address

316 E 123RD CT S
JENKS OK
74037-4296
US

V. Phone/Fax

Practice location:
  • Phone: 918-579-6100
  • Fax:
Mailing address:
  • Phone: 806-236-3080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number645507
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: