Individual
VAN NGO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
4413 SOUTH LEE AVE, OKLAHOMA CITY, OK 73109
(405) 631-0611
Mailing address
4413 SOUTH LEE AVE, OKLAHOMA CITY, OK 73109
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
R 0075671
OK
Other
Enumeration date
11/10/2014
Last updated
11/10/2014
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