Healthcare Provider Details

I. General information

NPI: 1396891743
Provider Name (Legal Business Name): MICHAEL SHANE HULL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SO. BRYANT AVE SUITE 104
EDMOND OK
73034-6330
US

IV. Provider business mailing address

4900 S. MONACO ST #210
DENVER CO
80237-3486
US

V. Phone/Fax

Practice location:
  • Phone: 405-715-2022
  • Fax: 405-715-2905
Mailing address:
  • Phone: 405-715-2022
  • Fax: 405-715-2905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4302
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4302
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: