Provider Demographics
NPI:1396144580
Name:MILBY, MATTHEW WAYNE (CRNA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WAYNE
Last Name:MILBY
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 1:2647 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5811
Mailing Address - Country:US
Mailing Address - Phone:901-647-0609
Mailing Address - Fax:
Practice Address - Street 1:2647 E 20TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5811
Practice Address - Country:US
Practice Address - Phone:901-647-0609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK114281367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered