Provider Demographics
NPI:1114956547
Name:RICHARDSON, MARK LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LYNN
Last Name:RICHARDSON
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:PO BOX 13618
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73113-1618
Mailing Address - Country:US
Mailing Address - Phone:405-715-3610
Mailing Address - Fax:405-715-3612
Practice Address - Street 1:9600 BROADWAY EXT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7408
Practice Address - Country:US
Practice Address - Phone:405-715-3610
Practice Address - Fax:405-715-3612
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0035247367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK246530401Medicare ID - Type Unspecified