Provider Demographics
NPI:1932394285
Name:RICHARD NEIL FORTUNE CRNA PC
Entity Type:Organization
Organization Name:RICHARD NEIL FORTUNE CRNA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:FORTUNE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:580-357-8198
Mailing Address - Street 1:412 SW LANDMARK CIR
Mailing Address - Street 2:
Mailing Address - City:GERONIMO
Mailing Address - State:OK
Mailing Address - Zip Code:73543-5144
Mailing Address - Country:US
Mailing Address - Phone:580-357-8198
Mailing Address - Fax:
Practice Address - Street 1:412 SW LANDMARK CIR
Practice Address - Street 2:
Practice Address - City:GERONIMO
Practice Address - State:OK
Practice Address - Zip Code:73543-5144
Practice Address - Country:US
Practice Address - Phone:580-357-8198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0048255367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty