Provider Demographics
NPI:1548461239
Name:WORTHINGTON, WILLIAM GEORGE (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GEORGE
Last Name:WORTHINGTON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:GEORGE
Other - Last Name:WORTHINGTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:30226 S HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:COOKSON
Mailing Address - State:OK
Mailing Address - Zip Code:74427-2255
Mailing Address - Country:US
Mailing Address - Phone:918-458-3100
Mailing Address - Fax:918-458-3511
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:918-458-3511
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55566367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered