Provider Demographics
NPI:1649353533
Name:BASHAW, JAMES MARTY (CRNA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MARTY
Last Name:BASHAW
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 1:35907 E COUNTY ROAD 1600
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-9070
Mailing Address - Country:US
Mailing Address - Phone:877-803-7306
Mailing Address - Fax:281-605-5792
Practice Address - Street 1:35907 E COUNTY ROAD 1600
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-9070
Practice Address - Country:US
Practice Address - Phone:877-803-7306
Practice Address - Fax:281-605-5792
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0075945367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100847130AMedicaid
OK100847130AMedicaid
OKOK402996Medicare PIN