Provider Demographics
NPI:1740218866
Name:BRUCE, JASON SHANE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:SHANE
Last Name:BRUCE
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 1:18162 OLD MORRIS HWY
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447
Mailing Address - Country:US
Mailing Address - Phone:918-733-9824
Mailing Address - Fax:918-733-9825
Practice Address - Street 1:1401 MORRIS DR
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6429
Practice Address - Country:US
Practice Address - Phone:918-756-3177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR 0085091367500000X
MO2004003392367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO82100Medicare ID - Type UnspecifiedMISSOURI MEDICARE