Healthcare Provider Details

I. General information

NPI: 1255511309
Provider Name (Legal Business Name): JEQUITA DAWN SNYDER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 NW VETERANS BLVD
MIAMI OK
74354-1818
US

IV. Provider business mailing address

PO BOX 1832
PITTSBURG KS
66762-1832
US

V. Phone/Fax

Practice location:
  • Phone: 918-238-3074
  • Fax: 918-238-3076
Mailing address:
  • Phone: 620-231-1960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4583
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: