Provider Demographics
NPI:1528019569
Name:ROESLER, GRANT (CRNA)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:ROESLER
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 1308
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74702-1308
Mailing Address - Country:US
Mailing Address - Phone:936-676-8655
Mailing Address - Fax:
Practice Address - Street 1:1400 BRYAN DRIVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74702
Practice Address - Country:US
Practice Address - Phone:580-931-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERNA193066367500000X
OKR0076619367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200091550BMedicaid
OK239723502Medicare PIN