Provider Demographics
NPI:1124011317
Name:FITZ, JOHN D (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:FITZ
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 6418
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73506-0418
Mailing Address - Country:US
Mailing Address - Phone:580-591-1910
Mailing Address - Fax:580-536-2067
Practice Address - Street 1:1003 NW BECONTREE PL
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-4126
Practice Address - Country:US
Practice Address - Phone:580-591-1910
Practice Address - Fax:580-536-2067
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0030346367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100782280AMedicaid
A91997Medicare UPIN