Provider Demographics
NPI:1760484133
Name:STREETMAN, PHILIP NONE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:NONE
Last Name:STREETMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:MR
Other - First Name:PHILIP
Other - Middle Name:NONE
Other - Last Name:STREETMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0727
Mailing Address - Country:US
Mailing Address - Phone:918-649-3426
Mailing Address - Fax:918-649-3426
Practice Address - Street 1:500 POLK CREEK ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-5420
Practice Address - Country:US
Practice Address - Phone:918-649-3426
Practice Address - Fax:918-649-3426
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0023472367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK363399510002OtherBLUE CROSS BLUE SHEILD