Provider Demographics
NPI:1629105036
Name:LUTTRELL, EVAN W (CRNA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:W
Last Name:LUTTRELL
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 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-1515
Mailing Address - Fax:
Practice Address - Street 1:1044 SW 44TH ST
Practice Address - Street 2:SUITE 415
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3613
Practice Address - Country:US
Practice Address - Phone:405-609-1645
Practice Address - Fax:405-631-4820
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK76040367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered