Organization
BLACKHAWK MANGUM, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHANA DAVENPORT (INSURANCE CREDENTIALING SUPERVISOR)
(512) 681-3460
Entity
Organization
Contact information
Practice address
ONE WICKERSHAM DR, MANGUM, OK 73554
(580) 782-3353
(580) 782-2811
Mailing address
PO BOX 280, MANGUM, OK 73554
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
2208
OK
207Q00000X
Family Medicine Physician
Primary
2208
OK
363A00000X
Physician Assistant
2208
OK
363LF0000X
Family Nurse Practitioner
2208
OK
Other
Enumeration date
03/19/2008
Last updated
07/23/2008
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