Healthcare Provider Details

I. General information

NPI: 1790211795
Provider Name (Legal Business Name): MR. JUSTIN DON COLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 09/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 S 204TH EAST AVE
BROKEN ARROW OK
74014-5165
US

IV. Provider business mailing address

2000 S WHEELING AVE STE 701
TULSA OK
74104-5647
US

V. Phone/Fax

Practice location:
  • Phone: 918-955-1907
  • Fax:
Mailing address:
  • Phone: 918-748-7810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number82942
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: