MEDICARE: MR. JASON SHANE BRUCE CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	R 0085091	OK
2	367500000X	Certified Registered Nurse Anesthetist	2004003392	MO

General Provider Information

NPI Number	:	1740218866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON SHANE BRUCE CRNA

Provider Business Mailing Address
First Line	:	18162 OLD MORRIS HWY
Second Line	:
City	:	OKMULGEE
State	:	OK
Zip	:	74447
Country	:	US
Telephone Number	:	918-733-9824
Fax Number	:	918-733-9825

Provider Business Practice Location Address
First Line	:	1401 MORRIS DR
Second Line	:
City	:	OKMULGEE
State	:	OK
Zip	:	74447-6429
Country	:	US
Telephone Number	:	918-756-3177
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/09/2007

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