Provider Demographics
NPI:1588656235
Name:HANLEY, ROGER D (CRNA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:HANLEY
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 1:5005 SW MALCOM RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9701
Mailing Address - Country:US
Mailing Address - Phone:580-536-4141
Mailing Address - Fax:580-536-4242
Practice Address - Street 1:5005 SW MALCOM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9701
Practice Address - Country:US
Practice Address - Phone:580-536-4141
Practice Address - Fax:580-536-4242
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK33243367500000X
OKR0030656367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100781660AMedicaid
OK100781660AMedicaid