Healthcare Provider Details

I. General information

NPI: 1740695774
Provider Name (Legal Business Name): JUSTIN HOLBROOK APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2014
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S TELEPHONE RD STE 250
MOORE OK
73160-2969
US

IV. Provider business mailing address

1621 CHAMBERS ST
NORMAN OK
73071-7261
US

V. Phone/Fax

Practice location:
  • Phone: 405-237-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR0096294
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number96294
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: