Healthcare Provider Details

I. General information

NPI: 1629796974
Provider Name (Legal Business Name): PHP OK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 WALNUT DR
ARDMORE OK
73401-2354
US

IV. Provider business mailing address

1820 COMMONS CIR STE B
YUKON OK
73099-9518
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-9008
  • Fax: 580-223-5051
Mailing address:
  • Phone: 405-265-2778
  • Fax: 405-494-7274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGIE MCKINNEY
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 405-577-6571