Provider Demographics
NPI:1295138592
Name:PEACOCK, RYAN (CRNA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PEACOCK
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 1:400 RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-3823
Mailing Address - Country:US
Mailing Address - Phone:918-706-4858
Mailing Address - Fax:
Practice Address - Street 1:400 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-3823
Practice Address - Country:US
Practice Address - Phone:918-706-4858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK105032367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered