Healthcare Provider Details

I. General information

NPI: 1194260703
Provider Name (Legal Business Name): KENNETH BRIAN HURST APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W SHAWNEE ST
MUSKOGEE OK
74401-4144
US

IV. Provider business mailing address

31349 W COUNTY ROAD 1235
QUINTON OK
74561-1012
US

V. Phone/Fax

Practice location:
  • Phone: 918-910-5186
  • Fax:
Mailing address:
  • Phone: 918-232-3159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number205720
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number77838
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: