Provider Demographics
NPI:1700336393
Name:SCOFIELD, JEROMY RYAN (CRNA)
Entity Type:Individual
Prefix:
First Name:JEROMY
Middle Name:RYAN
Last Name:SCOFIELD
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 1:6539 S OLIVER ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-9071
Mailing Address - Country:US
Mailing Address - Phone:316-519-3770
Mailing Address - Fax:
Practice Address - Street 1:1900 N 14TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2035
Practice Address - Country:US
Practice Address - Phone:316-519-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK116018367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered