Provider Demographics
NPI:1861540858
Name:SCHROEDER, MARK ALAN (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:SCHROEDER
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 1:4500 S GARNETT RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5238
Mailing Address - Country:US
Mailing Address - Phone:918-392-2944
Mailing Address - Fax:
Practice Address - Street 1:6901 S OLYMPIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1843
Practice Address - Country:US
Practice Address - Phone:918-388-5701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK61134367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100787870AMedicaid
OK100787870AMedicaid