Provider Demographics
NPI:1194721159
Name:ROSE, ROBERT EUGENE (CRNA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EUGENE
Last Name:ROSE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12202 E OAK DR
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-5684
Mailing Address - Country:US
Mailing Address - Phone:918-342-0314
Mailing Address - Fax:918-481-5170
Practice Address - Street 1:6839 S CANTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3402
Practice Address - Country:US
Practice Address - Phone:918-494-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0044766163WG0000X
OK44766367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice