MEDICARE: BRYAN SHELTON

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	175T00000X	Peer Specialist		OK

General Provider Information

NPI Number	:	1477396653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN SHELTON

Provider Business Mailing Address
First Line	:	1609 NW 30TH ST APT 222
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-3628
Country	:	US
Telephone Number	:	405-548-7254
Fax Number	:

Provider Business Practice Location Address
First Line	:	1609 NW 30TH ST APT 222
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-3628
Country	:	US
Telephone Number	:	405-723-8909
Fax Number	:

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

Provider Enumeration Date	:	06/17/2024
Last Update Date	:	06/17/2024

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Directions to “ BRYAN SHELTON ” Practice Location

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