MEDICARE: MR. VANDER OLDEN APRN-CNP

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	363LF0000X	Family Nurse Practitioner	90183	OK

General Provider Information

NPI Number	:	1730539099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VANDER OLDEN APRN-CNP

Provider Business Mailing Address
First Line	:	8101 AZUREWOOD DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-6293
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7410 S MACARTHUR BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73169
Country	:	US
Telephone Number	:	405-682-4075
Fax Number	:

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

Provider Enumeration Date	:	06/17/2016
Last Update Date	:	10/23/2018

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