Healthcare Provider Details

I. General information

NPI: 1063525954
Provider Name (Legal Business Name): CANYON PARK MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E 19TH ST
EDMOND OK
73013-6618
US

IV. Provider business mailing address

1501 E 19TH ST
EDMOND OK
73013-6618
US

V. Phone/Fax

Practice location:
  • Phone: 405-348-6611
  • Fax: 405-348-9280
Mailing address:
  • Phone: 405-348-6611
  • Fax: 405-348-9280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number8699
License Number StateOK

VIII. Authorized Official

Name: TONYA LYNN KEITH
Title or Position: CLINIC MANAGER
Credential:
Phone: 405-348-6611