Healthcare Provider Details

I. General information

NPI: 1952360034
Provider Name (Legal Business Name): MICHAEL ALLEN VANLEAR P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 S 14TH ST
JAY OK
74346-3836
US

IV. Provider business mailing address

659 S 14TH ST P. O. BOX 780
JAY OK
74346-3836
US

V. Phone/Fax

Practice location:
  • Phone: 918-253-6418
  • Fax: 918-253-4066
Mailing address:
  • Phone: 918-253-6418
  • Fax: 918-253-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number151
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: