Provider Demographics
NPI:1740797695
Name:THAMES, DALTON BLAKE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DALTON
Middle Name:BLAKE
Last Name:THAMES
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 1:1412 ALLYSON CIR
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-7138
Mailing Address - Country:US
Mailing Address - Phone:318-344-3621
Mailing Address - Fax:
Practice Address - Street 1:1200 E PECAN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6141
Practice Address - Country:US
Practice Address - Phone:580-379-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-01
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK128248367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200747670AMedicaid