Provider Demographics
NPI:1457350142
Name:ANDERSON, ROBERT LOUIS (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LOUIS
Last Name:ANDERSON
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 1:5 PATRICIA PL
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-7770
Mailing Address - Country:US
Mailing Address - Phone:918-470-9556
Mailing Address - Fax:918-493-6373
Practice Address - Street 1:6140 S MEMORIAL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-1933
Practice Address - Country:US
Practice Address - Phone:918-252-2020
Practice Address - Fax:918-307-1983
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0031375367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
353170ZJBTMedicare PIN
OK73-1553992Medicare UPIN
OK353170YR94Medicare PIN