Provider Demographics
NPI:1588446678
Name:DREAM WEAVER ANESTHESIA LLC
Entity type:Organization
Organization Name:DREAM WEAVER ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAITLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP-A
Authorized Official - Phone:918-282-9266
Mailing Address - Street 1:1601 S LEWIS PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5122
Mailing Address - Country:US
Mailing Address - Phone:918-282-9266
Mailing Address - Fax:
Practice Address - Street 1:9729 E 79TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4566
Practice Address - Country:US
Practice Address - Phone:918-250-5030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1538684428Medicaid