MEDICARE: PARADIGM HORMONES TULSA, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center		OK

General Provider Information

NPI Number	:	1417303801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARADIGM HORMONES TULSA, PLLC

Provider Business Mailing Address
First Line	:	6316 E 102ND ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-7061
Country	:	US
Telephone Number	:	405-703-7020
Fax Number	:	405-703-7021

Provider Business Practice Location Address
First Line	:	6316 E 102ND ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-7061
Country	:	US
Telephone Number	:	405-703-7020
Fax Number	:	405-703-7021

Authorized Official
Title or Position	:	INSURANCE CREDENTIALING
Name	:	NIKKI BUSELLATO
Credential	:
Telephone Number	:	405-703-7020

Provider Enumeration Date	:	05/04/2016
Last Update Date	:	05/04/2016

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