Healthcare Provider Details

I. General information

NPI: 1326794199
Provider Name (Legal Business Name): NATHAN M WADKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 JORDAN DR STE 102
PADUCAH KY
42001-7499
US

IV. Provider business mailing address

5312 W 41ST ST
TULSA OK
74107-6110
US

V. Phone/Fax

Practice location:
  • Phone: 270-297-2020
  • Fax: 270-297-2020
Mailing address:
  • Phone: 918-800-2020
  • Fax: 877-464-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number271288
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: