Healthcare Provider Details

I. General information

NPI: 1912333493
Provider Name (Legal Business Name): JANSON P VARGHESE APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S GRAND ST
CRESCENT OK
73028-9118
US

IV. Provider business mailing address

400 S GRAND ST
CRESCENT OK
73028-9118
US

V. Phone/Fax

Practice location:
  • Phone: 405-969-2818
  • Fax:
Mailing address:
  • Phone: 405-969-2818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number92801
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number92801
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: