1316939960 NPI number — JOHN W DEW II CRNA

Table of content: JOHN W DEW II CRNA (NPI 1316939960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316939960 NPI number — JOHN W DEW II CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEW
Provider First Name:
JOHN
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316939960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6418
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73506-0418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-591-1910
Provider Business Mailing Address Fax Number:
580-536-2067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1003 NW BECONTREE PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-591-1910
Provider Business Practice Location Address Fax Number:
580-536-2067
Provider Enumeration Date:
08/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R0040753 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100781740A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com