Provider Demographics
NPI:1558081166
Name:BRUBAKER, MACKENZIE (CRNA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4908 S JUNIPER AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-4422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3029 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3465
Practice Address - Country:US
Practice Address - Phone:918-701-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK210148367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered