MEDICARE: BROOKE JAVON DENTON CSFA

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	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1417472259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE JAVON DENTON CSFA

Provider Business Mailing Address
First Line	:	2924 S 98TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-4407
Country	:	US
Telephone Number	:	918-361-7366
Fax Number	:

Provider Business Practice Location Address
First Line	:	2924 S. 98TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129
Country	:	US
Telephone Number	:	918-361-7366
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2017
Last Update Date	:	07/21/2022

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