Provider Demographics
NPI:1629163126
Name:WITHROW, MICHAEL DEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:WITHROW
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 1:26 HILLCREST DR.
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604
Mailing Address - Country:US
Mailing Address - Phone:580-304-3881
Mailing Address - Fax:
Practice Address - Street 1:400 FAIRVIEW AVE
Practice Address - Street 2:SUITE 50
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1920
Practice Address - Country:US
Practice Address - Phone:580-762-0695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0054495367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered