Provider Demographics
NPI:1184799629
Name:MATHESON, RONALD LEE (CRNA)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:LEE
Last Name:MATHESON
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 1:2708 AMES AVENUE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604
Mailing Address - Country:US
Mailing Address - Phone:580-765-8319
Mailing Address - Fax:580-765-1447
Practice Address - Street 1:710 SO 13TH
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631
Practice Address - Country:US
Practice Address - Phone:580-363-9421
Practice Address - Fax:580-363-2339
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0029132163W00000X
OK26559367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse