Provider Demographics
NPI:1285609982
Name:OKUBO, PETER A (CRNA)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:OKUBO
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 1:10851 SW 30TH PL
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1541
Mailing Address - Country:US
Mailing Address - Phone:954-261-4106
Mailing Address - Fax:
Practice Address - Street 1:2120 NW 107TH TER
Practice Address - Street 2:#200
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33322-3418
Practice Address - Country:US
Practice Address - Phone:954-741-0636
Practice Address - Fax:954-741-0639
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3042592367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304183200Medicaid
FL304183200Medicaid
FLG2983ZMedicare ID - Type Unspecified