Provider Demographics
NPI:1902875479
Name:BRADY, RANDALL WATSON (CRNA)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:WATSON
Last Name:BRADY
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 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-542-6611
Mailing Address - Fax:918-787-3635
Practice Address - Street 1:200 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6830
Practice Address - Country:US
Practice Address - Phone:918-542-6611
Practice Address - Fax:918-787-3635
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0033098367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO911329803Medicaid
OK100786990AMedicaid
OK200468380NMedicaid
MO500156500Medicaid
OK900522214Medicare PIN
MO500156500Medicaid
MO911329803Medicaid
OK800522467Medicare PIN