Provider Demographics
NPI:1710900733
Name:DAVIS, WINDLE CLINTON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WINDLE
Middle Name:CLINTON
Last Name:DAVIS
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 1:1923 S UTICA AVE
Mailing Address - Street 2:BOX 217
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-6520
Mailing Address - Country:US
Mailing Address - Phone:918-744-3664
Mailing Address - Fax:918-748-7688
Practice Address - Street 1:1923 S UTICA AVE
Practice Address - Street 2:BOX 217
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-6520
Practice Address - Country:US
Practice Address - Phone:918-744-3664
Practice Address - Fax:918-748-7688
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0034086367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100784680AMedicaid
OK243604107Medicare PIN