Healthcare Provider Details

I. General information

NPI: 1508408311
Provider Name (Legal Business Name): MARCUS SHANE WAHL APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 N COUNTRY CLUB RD
ADA OK
74820-2847
US

IV. Provider business mailing address

2222 W IOWA AVE
CHICKASHA OK
73018-2738
US

V. Phone/Fax

Practice location:
  • Phone: 580-421-8700
  • Fax: 580-272-1094
Mailing address:
  • Phone: 405-224-8111
  • Fax: 405-825-4530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number58478
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: