Provider Demographics
NPI:1831138627
Name:ENDERSBY, JUSTIN TATE (CRNA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TATE
Last Name:ENDERSBY
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:RR 1 BOX 234
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-9712
Mailing Address - Country:US
Mailing Address - Phone:580-256-3956
Mailing Address - Fax:
Practice Address - Street 1:900 17TH ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-2448
Practice Address - Country:US
Practice Address - Phone:580-254-8492
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0084524367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered