Provider Demographics
NPI:1336241728
Name:SHOFNER, RAY (CRNA)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:SHOFNER
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:PO BOX 1664
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74402-1664
Mailing Address - Country:US
Mailing Address - Phone:405-947-5557
Mailing Address - Fax:405-948-6507
Practice Address - Street 1:300 ROCKEFELLER DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-5075
Practice Address - Country:US
Practice Address - Phone:405-947-5557
Practice Address - Fax:405-948-6507
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0033822367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731521875001OtherBC/BS OF OK