Provider Demographics
NPI:1487035598
Name:WILLIS, PAIGE (CRNA)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19004 BUTTERFLY BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9640
Mailing Address - Country:US
Mailing Address - Phone:785-764-2848
Mailing Address - Fax:
Practice Address - Street 1:5501 N PORTLAND AVE
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2074
Practice Address - Country:US
Practice Address - Phone:918-710-5114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS103716367500000X
OK115300367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK428451YM2HMedicare PIN