Provider Demographics
NPI:1093779407
Name:ROBERSON, MATTHEW W (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
Last Name:ROBERSON
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 1:1111 W WILLOW AVE
Mailing Address - Street 2:STE 106
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533
Mailing Address - Country:US
Mailing Address - Phone:580-252-6366
Mailing Address - Fax:580-252-4662
Practice Address - Street 1:1407 WHISENANT DR
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533
Practice Address - Country:US
Practice Address - Phone:580-251-8847
Practice Address - Fax:580-251-8869
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0076176367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered