Provider Demographics
NPI:1255668661
Name:DEBRUYCKER, JASON MATTHEW (RRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:DEBRUYCKER
Suffix:
Gender:M
Credentials:RRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:119 W HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-5909
Mailing Address - Country:US
Mailing Address - Phone:903-891-7000
Mailing Address - Fax:903-813-1479
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX083704367500000X
OK200483367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered