Provider Demographics
NPI:1689779381
Name:MARTIN, GARY L (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:MARTIN
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 3456
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-3456
Mailing Address - Country:US
Mailing Address - Phone:918-333-3830
Mailing Address - Fax:918-333-3846
Practice Address - Street 1:3500 E FRANK PHILLIPS BLVD
Practice Address - Street 2:JPMC ANESTHESIA DEPT
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2411
Practice Address - Country:US
Practice Address - Phone:918-331-1555
Practice Address - Fax:918-331-1695
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0030164367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100788020AMedicaid
OK100788020AMedicaid