Provider Demographics
NPI:1770581001
Name:TOOMBS, TERESA LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:TOOMBS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:TOOMBS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451-0579
Mailing Address - Country:US
Mailing Address - Phone:918-772-0990
Mailing Address - Fax:
Practice Address - Street 1:1400 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3324
Practice Address - Country:US
Practice Address - Phone:918-453-2148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK93952367500000X
MI4704279215367500000X
TX572751367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88460UOtherBCBS
AR154341701Medicaid
MI4308712170OtherBCBS
TX166116702Medicaid
MI1770581001Medicaid
AR82710OtherBLUE CROSS
TX83898UOtherBLUE CROSS
TX166116701Medicaid
TX166116701Medicaid
AR82710OtherBLUE CROSS
MI4308712170OtherBCBS
P00120201Medicare ID - Type UnspecifiedRAILROAD
TX166116702Medicaid
TX8L5135Medicare PIN