Provider Demographics
NPI:1669116455
Name:MOONLIGHT ANESTHESIA CONSULTING INC
Entity type:Organization
Organization Name:MOONLIGHT ANESTHESIA CONSULTING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNA
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILMARTH
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:405-213-5351
Mailing Address - Street 1:2115 BELLAIRE DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4206
Mailing Address - Country:US
Mailing Address - Phone:405-213-5351
Mailing Address - Fax:
Practice Address - Street 1:3705 NW 63RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1935
Practice Address - Country:US
Practice Address - Phone:405-213-5351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1003245481Medicaid