Provider Demographics
NPI:1255311791
Name:ROBERTSON, MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROBERTSON
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 26901
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-0901
Mailing Address - Country:US
Mailing Address - Phone:405-271-4351
Mailing Address - Fax:405-271-8695
Practice Address - Street 1:8801 S 101 E AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-294-4915
Practice Address - Fax:918-294-4947
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0087817367500000X
KS55476367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200120020AMedicaid
OK900522349OtherMEDICARE GROUP PIN
OK349242001Medicare PIN