Healthcare Provider Details

I. General information

NPI: 1841121613
Provider Name (Legal Business Name): TASHA RENEE' VICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MEDICAL PKWY
CLAREMORE OK
74017-1088
US

IV. Provider business mailing address

3100 MEDICAL PKWY
CLAREMORE OK
74017-1088
US

V. Phone/Fax

Practice location:
  • Phone: 918-273-1841
  • Fax:
Mailing address:
  • Phone: 918-273-1841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: