Healthcare Provider Details

I. General information

NPI: 1356948301
Provider Name (Legal Business Name): ANDREW RYAN SKOUSEN DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W 125TH PL S STE 200
GLENPOOL OK
74033-5026
US

IV. Provider business mailing address

11001 E 13TH ST
TULSA OK
74128-4221
US

V. Phone/Fax

Practice location:
  • Phone: 918-224-7305
  • Fax:
Mailing address:
  • Phone: 405-762-2563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0116201
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: