Provider Demographics
NPI:1144217464
Name:WIPFLI, PETER GEORGE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:GEORGE
Last Name:WIPFLI
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 10736
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73140-1736
Mailing Address - Country:US
Mailing Address - Phone:405-769-9218
Mailing Address - Fax:405-769-9218
Practice Address - Street 1:2825 PARKLAWN DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4201
Practice Address - Country:US
Practice Address - Phone:405-610-4411
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0022628367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK730927322002OtherBCBS
OK730927322003OtherTRICARE