Healthcare Provider Details

I. General information

NPI: 1013428903
Provider Name (Legal Business Name): BRIAN ALAN MIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2874 S OAK TREE LN
ATOKA OK
74525-5434
US

IV. Provider business mailing address

2874 OAK TREE LANE
ATOKA OK
74525
US

V. Phone/Fax

Practice location:
  • Phone: 580-239-1735
  • Fax:
Mailing address:
  • Phone: 580-239-1735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: