=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669937793
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW WOOD CUMMENS CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2019
-----------------------------------------------------
Last Update Date | 12/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S BLISS AVE
-----------------------------------------------------
City | TAHLEQUAH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74464-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-458-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 S BLISS AVE
-----------------------------------------------------
City | TAHLEQUAH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74464-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-458-3115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | R0101470
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------