Provider Demographics
NPI:1306464789
Name:ABBOTT ANESTHESIA APRN-CRNA PC
Entity type:Organization
Organization Name:ABBOTT ANESTHESIA APRN-CRNA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNA
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:ABBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:405-922-3246
Mailing Address - Street 1:PO BOX 660257
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35266-0257
Mailing Address - Country:US
Mailing Address - Phone:205-979-5882
Mailing Address - Fax:205-979-1248
Practice Address - Street 1:3957 E COVELL RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6909
Practice Address - Country:US
Practice Address - Phone:405-285-7246
Practice Address - Fax:405-513-8143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-11
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty