Individual
BILLY JACK PREMO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
2825 PARKLAWN DR, MIDWEST CITY, OK 73110-4201
(405) 360-7576
Mailing address
PO BOX 10979, MIDWEST CITY, OK 73140-1979
(405) 360-7576
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
R0025846
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100781950A
—
OK
01
—
430001523
MEDICARE PIN
OK
01
—
731189454001
BCBS
OK
Enumeration date
07/25/2006
Last updated
03/12/2015
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