Healthcare Provider Details

I. General information

NPI: 1922518232
Provider Name (Legal Business Name): BRYAN MARSHALL TISON PNP-PC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E 15TH ST STE 400A
EDMOND OK
73013-6673
US

IV. Provider business mailing address

2000 E 15TH ST STE 400A
EDMOND OK
73013-6673
US

V. Phone/Fax

Practice location:
  • Phone: 405-341-1697
  • Fax: 405-341-2672
Mailing address:
  • Phone: 405-341-1697
  • Fax: 405-341-2672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number101670
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: