Provider Demographics
NPI:1558327924
Name:BENNETT, JASON W (CRNA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:W
Last Name:BENNETT
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 1:1323 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4306
Mailing Address - Country:US
Mailing Address - Phone:405-742-5300
Mailing Address - Fax:405-742-4990
Practice Address - Street 1:1323 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4306
Practice Address - Country:US
Practice Address - Phone:405-742-5300
Practice Address - Fax:405-742-4990
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55187367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200109470AMedicaid
OK010672601002OtherBCBSOK
OK010672601002OtherBCBSOK
KS145006Medicare ID - Type Unspecified